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HomeMy WebLinkAbout17-052l IDENTIFICATION NO. / % — _ J (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday— Friday) 410 EaSI Washington Street Iowa City. Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (319) 356-5497 FAX First Middle Last 1. Name (REQUIRED) .'ut!gm(> n mom hrvbUcf S i, r i r- 2. 2. Address (REQUIRED) 3. Contact Information (REQUIRED) Email:o Inairna— rkl!% �ct)1^r inn, Cell Phonek3- JM1� 5 X03 ( wnAll 'tten communication sent via email) 4a. Driver's License expiration date (REQUIRED) 9- / S — 2 1�) r,� b. Taxicab Business Name (REQUIRED) d o wca n 'T-rzcJ4 P 0% ID 5. Prior experience in transportation of passengers: YVS n Lo,r kc, to Sr k y-,1 6US SLf Vi tle , c,1 L i4 V CAi 0,1,' IAC ip 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere Ah Type of offense What happened to the charge? (Circle one) Where Convicted Dismissed Deferred Suspended Plead Guilty Have you been arrested / charged with any traffic offenses in the last five years? %P S Type of offense cc;,/A6 0/24 to the charge? (Circle one) Where I,/ When Other When /3 Convicted Dismissed Deferred Suspended csiGuil Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 42 Type of offense Where When 9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please provide the name(s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW You must apply for an individual Department of Criminal Investigation Report (form available upon request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereb certify that I have issued to me by the Iowa Department of Transportation valid Driver's license number � }f0 issued on 6/zz1,'3 expiring on fl & 3 . I understand that if I falsely answer any questions in this application, that this application may be denied. I agree that in making this application, I consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examine any and all records and documents relating to this application, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicantl„ Date o� STATE OF IOWA ) COUNTY OF JOHNSON ) Sypscribed and Y� sworn to before me by �Ac l� \k\.Yh , St^�r` on this day of SNotary Pu lic in and for the State of Iowa '73(1-7 I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). Expiration date of Driver's license 4,114091Z4 t2S� Signature of Police Chief or designee �/-.7 17 Date AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. jo Ar /I- � 47111 Signature of City. Clerk or designee Date }+'##+#}**++ilflHlxH4!#HlHHl1H!**f f*f*xRHxllx}}H*R1f}}!f**+*}}+#}+#*H#+}#Hf!!fl11H11flHHf!llxxHflHlH!!ll1Hf!#Yf1HHHHlHHHf Office Use Only Approved application DCI report State certified driving record Website update CIeMaA%IDRN ADGEAPPL9201demmded.DOC 07/2016 � Fram:clry A t -r0 m:0i1v a ,a J}}u 2017 9 : 0 2 A M Div of Criminal Investigation 01 IDwe CI1y OICrk Office 319 3666467 IN 1-10 Clly Clork OIIiCC Zle 3685497 No. W9 Y. 1/1 06/06/2019 11:01 'IGO4 Y.001/002 03/29!2017 11:21 4CriRnfSTATE' OF J()VVA !24 Recos•e Check 1. To: .Last l-ILC.n F lOwn Division of Criminal lgvcstlgatil Support 011e1•atthae Bureau, Irl Noor 215 E, I" street Des Moines, luwa S0319 0:15) 725-6090 Far: Or 7 d F; - I -? 6-1 J n i-1 n-) cq rl +090 p non/0" i Qz' DC.'JAceountIqunlher: Lf(� Z ,iIA(' (i(appliaablc) ).(1/>. v 'F;•Um: _City of 1oo:•a Cay City Cteri�i's Office - --- _ Phone; 319-356-5041 Fax: 319-356-5497 ©Female IMS lnvn6v�� �dn)6 —5 "1 .�-I 6[f n'IgVer "JOrfttq(i011- Without s signed waiver boll, the subject of the request, a complete criminal history record may nal he releasable, per Code of lova, Chapter 692.2. 1('oe camjilcfe criminal history record Information, ns alloll•ed Uy law, alwa)�s obtain a waiver sinnature from the a ssuhjcct of the retwest. J'1/f/!I@Y ,7f @(@Ilse; 1 h=rsby give perosisEiml rot the ebave hlvesligalian Incl), MY elmlinll hislcrydafl concerning hipq As of Waiver Sfg nuture; sl Io (lie nn 10117 eale qai htnefy by li thee{: pith the DiYi5i011 ofCriMhtll by the DCI mny he tdeasad as alleuxd by lair, • I ---..-...-..." ua,c ul olrin revealed: 1\0 10N'fi C17111111a11{]SI01')r Record found with DCI To"' Criminal 1-Tista]')' Record attached, DCI # DClDCI-77 (081215110) inilials�. iaceived Tirar• War 7q )61-1 ii•l1661J: M,1 9i0. Received Time Aur. 5.' 2017 '10;47AM"f o. 6613 Iowa Department of Transportation i 0 Ohm of Driver Bermes (Tall Faee) 80&-532-1121 PO Box 9204, Um, Moinas, IA 50306 0204 515-244-9124 FAX: 515-239-1837 Certified Abstract of Driving Record Inquiry Date: 4/7/2017 DL/ID #: 679AJ0237(IA) Customer #: 6073198 Name: Sharif, Ayman Class: B ID Status: None 03/08/2014 Mahmoud Mohamed S92 Speed (10 mph & under in 35-55 mph zone Johnson IA Address: 1901 GRYN DR Audit #: 7062538 DL Status: VAL 12/18/2015 03/08/2016 Issue Date: 06/22/2013 CDL Status: VAL City/State: IOWA CITY, IA Expiration Date: 09/18/2018 CDL Cert Status: Excepted Intrastate 522464408 Endorsements: PS CDL Med Status: None Mailing Address: 1901 GRYN DR Restrictions: NONE Restriction None Supplement: Date of Birth: 9/18/1967 Mailing IOWA CITY, IA Sex: M City/State: 522464408 History Information Convictions Citation Date Conviction Date ACD Explanation County ]UR 09/01/2013 09/27/2013 S92 Seed Johnson IA 03/08/2014 04/08/2014 S92 Speed (10 mph & under in 35-55 mph zone Johnson IA 01/25/2015 04/14/2015 S92 Seed Johnson IA 12/18/2015 03/08/2016 M14 Fail to Obey Traffic Sign/Signal Johnson IA Name: Sharif, Ayman Mahmoud Mohamed DL/ID: 679AJ0237 Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I am the custodian of the records held by the Office of Driver Services, that this is a true and accurate copy of an official record currently in the custody of said Office, and that I have been authorized by the Director of the Iowa Department of Transportation to so certify. In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date: