HomeMy WebLinkAbout17-089CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(319) 3S6-5497 FAX
1. Name (REQUIRED) _
IDENTIFICATION NO. %i — C> J7-5 -L
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
Failure to complete the "required" information will result in denial of the application
First B _ 1, �, A -V\X Middle RV A5HAHA ll D Last A L(�) A Ptit
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2. Address (REQUIRED) _ g�/ Cye'--6 ` a/K &-\L4 C lou 4 �eN
3. Contact Information (REQUIRED) Email: ejeun m rito(16 ci Ml it •c-0411 Phone: 314 d -4-I -4:iEH
(All written communication sen is email) yGo - j7-3 3 4
4a. Driver's License expiration date (REQUIRED) 1 B 23 / 2or 4
b. Taxicab Business Name (REQUIRED) at K Colo CKS ( .,.9 OIL C'G-
5. Prior experience in transportation of passengers: Cam- GA
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere NO
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other��
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Have you been arrested /charged with any traffic offenses in the last five years? � ,,., T� O
Type of offense Where D
What happened to the charge? (Circle one)
Convicted Dismissed
C1
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:t o
Deferred Suspended Plead GA; Otger
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 bean Iowa City taxi driver using a different name? If yes, please provide the name(s)
N'n
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 hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
S9 G A F+ I 6 9 issued on 1) / z81 16 expiring on to / 23 1 1.fi . 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 Titl hapter2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant I� ubDate T/_F/ / ) 1ro
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STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by $rrkQVP-[Aj ,n A Alclrr,cc�1_ on this -- day of
the State of
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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 CyS, c4Iowa CityTitle 5, Chapter 2, City Code).
IoI 23 � I�
of
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Dat
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.
Si nature of City C r{ or designee
-/--7-/-7
Date
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Gerk/TMIDRWa4DGEAPPL92014a.dn .DOC 07/2016
Office Use Only
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Approved application
DCI
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report
State certified driving record
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Website update
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Gerk/TMIDRWa4DGEAPPL92014a.dn .DOC 07/2016
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SMA I SIMPLER ERIC 5T MEft
Office of Driver Services
PO Box 92041 Des Moines, IA -.50306-9204
Phone -"515-244-9124 1800-532-1121 1 Fax: 515-239-1837
www.lowadot.gov
Certified Abstract of Driving Record
Inquiry 6/30/2017 DL/ID #: 596AH4569 (IA) CDL Permit Class: None
Date:
Customer 5955498 Class: D CDL Permit Issue None
#: Date:
Name: Algaali, Bahaeldin Audit #: 1514255 CDL Permit None
Akasha Expiration Date:
Address: 845 CROSS PARK AVE Issue Date: 12/28/2016 CDL Permit None
APT 3C Endorsements:
Expiration 10/23/2017 CDL Permit None
Date: Restrictions:
City/State: IOWA CITY, IA Endorsements: 3 ID Status: None
522404472
Mailing 845 CROSS PARK AVE Restrictions: NONE DL Status: VAL
Address: APT 3C Restriction None CDL Status: None
Mailing IOWA CITY, IA Supplement: CDL Permit ELG
City/State: 522404472 Status:
Date of 10/23/1973 CDL Cert Status: None
Birth:
Sex: M CDL Med Status: None
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number �IUR
01/22/2014 --7 —
81326 -- ---- I•"-_ -----
Name: Algaali, Bahaeldin Akasha DL/ID: 596AH4569
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:
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6/30/2017
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IOWA .�*W
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DBI
Office of Driver Services
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Iowa Department of Transportation
http://172.29.254.55/drivers/reports/customerhistorylcertifieddrivingrecord.aspx 6/30/2017
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Name: Algaali, Bahaeldin Akasha DL/ID: 596AH4569
http://l72.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 6/30/2017
Fe-JuI. h. 201/,, 1:11I'M,„r,Uiv of Criminal Investigation O6/2012aY 15:4 No,4h43.O..Y. .1,02/002
�£STATR, OF IOWA
Cidl:Wnal History Record Check
g �Y” 1nWA y` t 5
•+�CRequest ]Form
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nv.n.
]-JCI AoeountNumben 4o o 2 —�
(ifapphcabic)
To:]owaDivision ofcriminalInvestigation From: City oflowacity _
Support Operations Bureau, V Floor City Cleric's Office --
215 & 7"' Street 41011, Washington Street
Des Moines, lows 50319
(515)725-6066 Town (`its_ Ta R»dn
(515)725-6060 Fax
Phone: 319356.5041
Fal: 319-356-9497
1 am reouestina an TnwA Criminal Taistnsv Reenrd MPA- nn•
L28t Name (mandatory)
First Name (inandwary)
Middle Name (Ieconiniendcd)
ALCgA4L 1
1AHAELD t�J
/SVA HAAHAIE.D
Date of Birth (tnandalap)
Gender (mandatory)
Social Secturitv Number (rtcon,mendea)
16V23.11573
�INfale ❑Female
22�j- qq - 4
Waiver rnjorMafion! Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code of Iaws, Chapter 692,2, For Complete criminal history record informetioiy as allowed by lacy, always
obtain a waiver signature from the sub•ect of the request.
W(tiver Releasee 1 hereby give permission tar die above ecqucaling official In canductno lovacdminal history record chcek with We bivision of Criminal
hn esligalion (DCI). Mywlminalhis,orydslneoneerningm maintained bydrpb(Clmaybercicased as allowed bylaw.
WetiverSignalare: �r
Iowa Criminal History Record Check Results (PC] use only)
As of a search ofthe provided name and date of birth revealed:
No Iowa Criminal History record found with DCI s
❑ Iowa Criminal IIistory Record attached, DCl # ;
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DCI initialst
DCI -77 (09/25/10)
Received Time Jun. 26. 2017 4:21PM No, 2060