HomeMy WebLinkAbout17-097SSSV� Ak � It 11 � — 1 r v \ I
t IDENTIFICATION NO. / .7 - T) —Z— C;-�
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APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
C ITY OF IOWA C ITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday- Friday)
410 East Washinston Slreel
Iowa City. Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(319)l356-5040
(319) 3S6-5497 FAX
t -� ast I
1. Name (REQUIRED)FirsMiddle
2. Address (REQUIRED) Z3 ,i t-.1 P� j c'r f Y
3. Contact Information (REQUIRED) Email: 'I-'
/ Nr [ Z t A0 �MgltCell Phone: 311-333 A! 94
��t ✓'�' �6�.�
(All written communi�Fation sent vla email)�f
4a. Driver's License expiration date (REQUIRED) 'it, b / 2 ) 144
b. Taxicab Business Name (REQUIRED) _A "l -'s 6V SQ L l P
5. Prior experience in transportation of passengers: -7 y rd/ f
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? N d
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? Aa S
Type of offense What When
What happened to the charge? (Circle one)
Conic ' Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where
When
9. Have you ever applied to be an 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)
0712016
• APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby c7r7t that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
`Q 1 issued on o Z406113expiring on X121 /Ig . 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, ofa City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant M Date / I N
STATE OF IOWA )
COUNTY OF JOHNSON ) / 11
Sub c ibed and sworn to before me by G � y k 1 \�— � n ' a 6 L M�� n this 1 `1� day of
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).
Expirati da o nve license /41 / 1
Sig atur o ief or designee 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.
Signa ity Clerk br desi ee ���
Office Use Only
Approved application
DCI report
State certified driving record
Website update
amffAMDa,vaacr',w, 201, ,,,m,eo,noc 0712016
C1J1u6"WA00T SMARTER I SIMPLER I CUSTOMER DRIVEN WWW'toWadot.gov
Inquiry
Date:
Customer
Name:
1/31/2017
2345972
Page 1 oft
office of Driver services
PO Box 9204 1 Des fdoines, IA 6030&9204
Phone: 515-244-9124 1800-532-11211 Fax: 515-239-1837
w aJowadoLgov
Certified Abstract of Driving Record
DL/ID #: 617XX3616 (IA) CDL Permit Class: None
Class: A
Abdallah, Elfatih Hussein Audit #: 7169570
Address: 16 ANISTON ST
City/State:
IOWA CITY, IA
Expiration Date:
522402216
Mailing
16 ANISTON ST
Address:
CDL Permit
Mailing
IOWA CITY, IA
City/State:
522402216
Date of
6/21/1972
Birth:
Sex:
M
Convictions
Issue Date: 07/25/2013
Expiration 06/21/2018
Date:
Endorsements: NT
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Restriction None
CDL Permit
None
Endorsements -
CDL Permit
Col. Permit
None
Restrictions:
'IA
ID Status:
None
Restrictions: NONE
DL Status:
VAL
Restriction None
CDL Status:
VAL
Supplement:
CDL Permit
ELG
12/03/2011
Status:
'IA
11/22/2016
CDL CertStatus:
Excepted Interstate
CDL Med Status:
None
History Information
Citation Date Conviction Date ACD Explanation County SUR
01/13/2013 '02/21/2013 'S92 .Speed Iowa IA
Accidents - Accident Involvement Indicated does NOT mean the individual was at fault or given a citation.
Accident Date
Case Number
3UR
11/20/2008
1472653
IA
D6/24/2010
_ 378332
IA
12/03/2011
_
66053_0
'IA
11/22/2016
953877
IA
Name: Abdallah, Elfatlh Hussein DL/ID: 617XX3816
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 saidoffice, 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:
1/31/2017
Jan. J3, 2017 9:24AM Div of Criminal Investigation No, 1285 P. 1/1
Arom:OlrY of Iowa City Claris Orttoe 310 3666687 01/10/2017 16:46 /1767 P,002/002
STATH OF IOW A
1 Request Form �
DOIAccount Number:
Ofapplicahla)
To: lona Blvlslon of Criminal Investigation
Support Operations Bureau, V Floor
215 E. T" street
9 f....1.fWI,.VMi YNYIY
(51 5) 725-6066
• (5I5)•S2S6U80"Ita>--' "
1 .. ..4:.... .... t.,. r«—Inns ViMnw "ne d C6oA4 A.-
From: City of lawn ON
City Clerk's Office
410 G; t'Vasldngton Str(5et
Iowa City, IA $2240
Phone; 319-356-5041 -
Fast 319-356.5491
iasf Name (mandate Y)
First Name (nimilblor4
Middle Name retonmtedded
Al ak
H
Date of Birth (mai,dalo
Gender (mnnd,tM)
Social Security Number (mcotnmendcd)
ei /'?1 / I q 7 2-
Nieto ❑Female
Wttilier YH,/ornlation: Without a signed waiver from the subject orthe request, a complete criminal history record may not
be releasable, per Code of lovvar Cliapler 692.2. Tor complete criminal history record Information, as allotred by law, always
obtain a witIversiggaturelromthosablectOfther ucst
Waiver B0100e: a hereby sive pctmbsion for the above mquut ng offitiol to conducun logo triininal hii(n mord chtrY ailh dtcDlvnion ofCtimind
imsnigation(DcD. Any uhninal history data concealns tnc ami It mabdclmd by We DCl maybe clemcdnsallowilbylnv.
Waiver Signature; k'
As of l' 13 I 1 _ , a search of the provided name and date of birth itlitaled:
No Iowa Criminal I•Iistory Record found with I)CT
❑ lows Criminal History ]record attached, DO g
DO initials rk
DCI -77 (08/25/10)
Ral'41Vnil Timo .Ian 10 9017 1.96PM No 1768