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HomeMy WebLinkAbout17-118( R 1 � t CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 3S6-SO40 (319) 356-5497 FAX IDENTIFICATION NO. / —7 — 1 IF) (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 resuk in denial of the avalication First Middle La'stJ�, 1. Name (REQUIRED) i� 6d�C�a wtG n A"\ U%I tM%�e� q 6 ��V 'a% 2. Address (REQUIRED)X21 Baj,,rtr,C 421) aPj r2n i 22 3. Contact Information (REQUIRED) Email: Ko IAT% 09 8 e - c .n Cell Phone: _3 ( c) Ji 30 -76 S P (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) IT I) c> I / `Z O 4} 6 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? Type of offense What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense JN Where When I✓�rfiC. (-IArLK,1 ciVNKS�� b 11 -DI�� What happened to the charge? (Circle one) Convicted 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? go Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please p pvi a t9name.(AzX { v 0 �� w r DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATTOW D m DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE 0W REVIEW© 7 You must apply for an individual Department of Criminal Investigation Report (form avalAle upi�grequest). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 07/2016 r , , 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 ,)� 14d l q Q �� issued on 0 1;43e,) /17 xpiring on of/o/� 2020 . 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 Applicant�� Date 5 /30 / I -_-� STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by Av„ on this X O day of 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). Dqe 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. /30 Sign ture of City Clerk or d signee g fD// / Office Use Only Approved application DCI report State certified driving record Website update derv✓rnxiDwVBADG PPL92014amnded.DOC 07/2016 N a •� -� n r 3 -77 � w .o derv✓rnxiDwVBADG PPL92014amnded.DOC 07/2016 ''.gI � r. DOT SMARTER I SIMPLER 1 CUSTOMER DRIVEN www.iowadotgov Office of Driver Services PO Box 9204 i Des Moiries, lA 50306-9204 Phone: 515-244-9124 1800-532-1121 1 Fax: 515-239-1837 www-iawadot.gov Certified Abstract of Driving Record Inquiry Date: 8/30/2017 DL/ID #: 214CC9840 (IA) CDL Permit Class: None Customer #: 4313828 Class: D CDL Permit Issue None 09/19/2015 09/28/2015 M08 Fall to Obey Officer Date: Johnson Name: Abdelrazig, Abdel Rahman Audit #: 1843731 CDL Permit Expiration None Mohamed Date: Iowa Department of Address: 2525 BARTELT RD APT 2D Issue Date: 05/30/2017 CDL Permit None Endorsements: Expiration Date: 01/01/2020 CDL Permit None Restrictions: City/State: IOWA CITY, IA 522462718 Endorsements: Chauffeur 3 ID Status: None Mailing 2525 BARTELT RD APT 2D Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing IOWA CRY, IA 522462718 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 1/1/1956 CDL Cert Status: None Sex: M CDL Med Status: None History Information Convictions Citation Date Conviction Date ACD Explanation 3UR County 11/12/2014 11/25/2014 S92 Speed (10 mph & under In 35-55 mph zone) IA Washington 09/19/2015 09/28/2015 M08 Fall to Obey Officer IA Johnson Accidents - Accident involvement Indicated does NOT mean the Individual was at fault or given a citation. Accident Date 3UR Case Number 09/08/2012 IA 702582 04/20/2015 IA 855323 03/20/2016 IA 912831 Name: Abdelrazig, Abdel Rahman Mohamed DL/ID: 214CC9840 (IA) Pursuant to Iowa Code 4321.10, 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 69 EtllClf p�`�yi 3�'--t w ®0 8/30/2017 7 'iii4�f\BRi�hS aDriver elTrznsportation Iowa Department of l� FAu�;2y 2017„11:35AM�QDiv of Criminal Investigation oat<2e ��:,�a,No.9461P. 1/4 1..,.,2r002 STATE OF IOWA Criminal History RecojA Check Request Form To: Iowa I)ivision of C1•iminal Investigation Support Operations Hures u, Is' Floor 215 E. 7'I' Street Res Mob,es, Iowa 50319 (515) 725-6066 (515) 725-6080 Fax an st A b is � Date of Birth 010(1131,"6 First Awe.l)-Ati Wta JXI Account Number _q_ DDZ _ (if opptirablc) �- From: _City of tpwfl City City Cleric's 4I0 B. wasllinglon 8^treet Iowa City, IA 52140 Phone: 319-356-5041 Fax: 319-356-5497 LLdlVlale ❑Female M {'l, o rvl Waiver Inforniatioti., without a signed waiver from the subject of the request, a complete crimbral history record may not be releasable, per Code of tows, Chapter 692.2. For complete criminal history record Information, as allowed by law, always obtain a walver sigynature from the subject of the repuest. Waiver ie/elrse: 1 hereby give permission for the above requesting officizl to conduct an Iowa criminal history record ehook will, the Division orCl{missa, bwes,igalioa (DCI). Any criminal history dais concerning me Thal is mohUained by she DCI maybe released as allowed bylaw, Waiver Signature: As of q \ ),t \ ki a search of the provided natne and date of birth /11 No Iowa Criinival History Record found whir DCI 0 Towa Criminal History Record attached, DCI # DCT initials—k.— DCI-77 nitialsDCI-77 (08/25/10) ~ Received Time Aug. 24. 2017 10;47AM No.9011 "00 use only) 0