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HomeMy WebLinkAbout17-096IDENTIFICATION NO. )1-0(1(49 r / (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 East Washington Street Iowa City. Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) 3. Contact Information (REQUIRED) Emaill )&&jC4,q ,a1.[,w Cell Phone:�&4 7X 4 (All written communication sent via email) 4a. Driver's License expiration date (REQ[ b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? A J C ) Type of offense Where When What happened to the charge? (Circle one) ro Convicted Dismissed Deferred Suspended Plead Guilty Qthe 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where What happened to the charge? (Circle one) r o Convicted Dismissed Deferred Suspended Plead Guilty Other M 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? N o 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) 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 r 1 hereN ce ify that I have issued to me by the Iowa DepartTent of Transportatio a v lid Driver's license number D lh o32 o ssued one expiring on 6 1 understand that if 1 falsely ans er any questions in this application, that this application may be denied. I a ree 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 i front of a Notary Public) r Signature of Applicant Date 0iS 0 1 Y}11f1f1ffflffYnfY«««}t!t!«f 1f«!!1f«114««f}f«f}!f-f«1«««i!f 41tH}}1!1111 f f 1f fYYY«}«Itf}!f 1f f «Y4f«iff 1«f«f f 1f«f f f}«111-1}ff« STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by C)SMor% \kctSSnn on this \3't day of •a ct a011 Q v \I,, in YlftfefflfeYY#1fi!!f-f 111414f14IY,�Rltfff!*RitYO;}4f««Ifffl,Yft4RRkhfefflt#Y.fff«««4Yff41tfRf*tfe*«4f i'11111«f4f�fIRYR}«y1f«f4}1f{fff«ff1'R«tfifilYf 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). date or designee g/Z/ 4/1 / L- � D to 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. Signature of City Clerk designee Date Office Use Only Approved application A? C DCI report State certified driving record n ::in-- I r Website update -<F y rn D 0 Derv✓rAvaow BADGEAPPLssoiaemeMW.Doc 07/2016 JU I. Z7• ZUI/ IU:47AM U i v o 6Y Ifni nal investigation Ao.)gII r. I FIGu�..��.Y �� .•+w= ._i.r CIer6 vn�.-v ., uuu.e. 07/21/2017 1a;6u n121 —021002 STATE OF IOWA It, l CtrLmhial History Rem rFei G"r et Ep i lh ;' Request Tit o rna MI Account Number; UC70Z (if applicable) To: lows Division of Criminal Investigation Fro In: City of lovva Support 6pers0ons Bureau, I" Floor City Clerk's Office 215 E. Te street 410 L. Washington street Des Moises, Iowa 56319 (51S) 729-6666 ("iar. IA ;Ilan (515) 725-6080 rax Phone: 319-356-5041 Tax; '319-356.5497 I am reauestina an Iowa Crhninal Histon, Record Check on: ]Last Name (maadaw) First ]lane (mandalory) Middle 1VeIm_e (reea,nn,ended) H AJ�U 0 � ©% �\G� (V')I nl 1 U1 M C J Date of Birth (maodalory) Gender (m.ndatory) Social Security Nulnber (recommended) Vale ❑>?eniale b Vi q- ct `1- 2 01 7 3 Waiver Ilafornlafiolld Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always obtain a waiver signature from the subject of the request. Waiver ReleaSe: rhercby give pennissian for the above requesting official to candaet an Iowa criminal histoq record cheek with the Division of Crlminel hlvniigation (DCI). Any criminal hismry date concemin, me that is main) mad by she DCI may be released as allowed by law. TT/afverSignature• Iowa Criming History Record Check Results As of� , a search of tho provided name and date of birth revealed; ,�rNo Iowa Crilnhlal Histovy Record found wilb DCI ® lotva Criminal history Record attached, DCl 0. DCT initials_ DCI -77 (06/25110) Received Time MAI, 2017 2;30M No 3306 (DCI use only) SMARTER I SIMPLER I CUSTOMER DRIVEN WWWA wadot.gov Office of Driver Services PO Box 9204 1 Des Moines. IA 50306-9204 Phone: 595-244-91241800-532-11211 Fax: 515-239-1837 www.iowadot.gov Certified Abstract of Driving Record Inquiry Date: 7/21/2017 DL/ID #: 103AM0320 (IA) CDL Permit Class: None Customer #: 6474944 Class: D COL Permit Issue None Date: Name: Hassan, Osman Mohamed Audit #: 1819037 CDL Permit Expiration None Date: Address: 209 HOLIDAY RD APT 317 Issue Date: 05/17/2017 CDL Permit None Endorsements: Expiration Date: 07/08/2021 CDL Permit None Restrictions: City/State: CORALVILLE, IA 522411134 Endorsements: 3 ID Status: None Mailing 209 HOLIDAY RD APT 317 Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing CORALVILLE, IA 522411134 Supplement: CDL Permit Status: ELG City/state: Date of Birth: 7/8/1970 CDL Cert Status: None Sex: M CDL Med Status: None History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Iccident Date Case Number IUR 19/03/2016 938734 IA 12/18/2017 969586 IA Name: Hassan, Osman Mohamed DL/ID: 103AM0320 Pursuant to Iowa Code 4321.10, 1, 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: `• aplf IOWA :afo D. 0. T.s,43n 7/21/2017 ....... Office of Driver Services 4tM•��o�� Iowa Department of Transportation Name: Hassan, Osman Mohamed DL/ID: 103AM0320