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HomeMy WebLinkAbout17-103 '♦ IDENTIFICATION NO. -7 r 1 (Offic Use n y) --- Ezir7Ast 411 RIF :III 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 (319) 356-5040 (319) 356-5497 FAX first Middle` 4c\t.,,ev\ 1. Name(REQUIRED) � INck nnC'�� e 2. Address (REQUIRED) PkC Y- d 7471 3. Contact Information(REQUIRED) Email: 11-M ( j � 3 Yakoo Cell Phone: \��\rL1— '2. (AI written communication sent via email) 4a. Driver's License expiration date (REQUIRED) 61-/ 'LCA 1 2,© 2- _ w MOP b. Taxicab Business Name (REQUIRED) C j A-1 Co-b j -� 5. Prior experience in transportation of passengers: C, C,el CI J! 6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State* 5ewhere? Type of offense Where When nr► What happened to the charge?(Circle one) Convicted Dismissed Deferred Suspended Plead Guilty/ Other 7. Have you been arrested/charged with any traffic offenses in the last five years? 'Y k 5 Type of offense F--;°:`" }" ° 62I fr (4.1c IA Where When n 4e(-34--- a Q �-. / W hat hag=to the ClUg+e?(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? .l 0_ S T e 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 0 �, 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 CY Z 6'A LSO° it issued on 04411111 expiring on o2.'10J 7 2 . 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 provi s of Ti , apter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applican Date n U 1 I ( f I .4- WENDY S.MAYER Commission Number 729428 My Commission Expires ow ************ ********-********************** ************************************ ********************IF*** ************ STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed �End sworn to before me by Kir..-1 ; X K. A _ Alit w i S on this 8 day of Au�u S.. Zoirl.i �/ � r? WENDY S.MAYER —J.4-)C)'1/4/4-1k4.--- Kms( ? r Commission Number 729428 Notary Public in afor the State of low •******************ir*****4 AA AA AA k******************4rk **********************************************************#***-A*#k*****iF*****rt****** 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). Expiratio date if a ver's icense 74 Z VI i 2 1/ 7 Signature • Poli, ri- 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. - e( (t..(' X, C-tte 71:4.,2.:4,- ,._d15- gnature of City Clerk/ r designee ?A/7 a e N ***** *****************************.***************************************************** l* ** ***** *************** _ 5 1042 a agn Office Use Only � �4.1.016 .r6 c3-< co 1 --...-.(g 1 m Approved application -a DCI report _ 0 State certified driving record Website update yj Get Oerk/TAXIDRIVBADGEAPPL92014amended.DOC 07/2016 .., 0 iti„ .,,, ,A DOT SMARTER I SIMPLER I CUSTOMER DRIVEN vvwvv.iowadot.gov Office of Driver Services PO Box 9204 I Des Moines,IA 50306-9204 Phone:515-244-9124 i 800-532-1121 i Fax:515-239-1837 www.iowadoLgov Certified Abstract of Driving Record Inquiry 8/8/2017 DL/ID #: 936AL8004 (IA) CDL Permit Class: None Date: Customer 6401617 Class: D CDL Permit Issue None #: Date: Name: Ahmed, Khalid Mohamed Audit#: 1738329 CDL Permit None Hamid Expiration Date: Address: 2420 BARTELT RD APT Issue Date: 04/11/2017 CDL Permit None 2C Endorsements: Expiration 02/20/2022 CDL Permit None Date: Restrictions: City/State: IOWA CITY, IA Endorsements: Chauffeur 3 ID Status: VAL 522462707 Mailing 2420 BARTELT RD APT Restrictions: Corrective Lenses, SR DL Status: VAL Address: 2C Required Restriction None CDL Status: None Mailing IOWA CITY, IA Supplement: CDL Permit ELG City/State: 522462707 Status: Date of 2/20/1991 CDL Cert Status: None Birth: Sex: M CDL Med Status: None History Information Convictions Citation Date Conviction Date ACD Explanation JUR County 03/15/2016 03/26/2016 ,S92 'Speed -NJ 03/15/2016 - - _ 03/26/2016 IM81 Careless Driving IIA- 06/15/2016 '07/02/2016 - - - - - 1 4 'Improper Registration IA_ _- Johnson 10/22/2016 ;12/04/2016 iM14 'Fail to Obey Traffic Sign/Signal 'IA Johnson Sanctions Type Effective End ACD Explanation JUR Occurrence JUR Suspended 101/10/2017 l04/09/2017 JW01 'Habitual Violator :IA NO 11 Name:Ahmed, Khalid Mohamed Hamid DL/ID: 936AL8004 (IA) 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: d 14-: ix.•,,d,, ,%A 8/8/2017 <;' IOWA '#t s : �, cJ e f /'II%et OAIVEI�%°� Iowa of Dartme Diver epartment ries Transportation Name:Ahmed, Khalid Mohamed Hamid DL/ID: 936AL8004 (IA) r-ronu.6.. J• _LVI /v. L_J,rlrS,arkuIv of mi�nai Investigation No. 4114 P. 1/1 — "' 07/3 Y/2017 11:0 .63 r-.�a /L)a2 • J • • ,<,, �vrv��� STATE OF IOWA �" u� Anima , Criminal History Recon di Check , "s 'a ,6 ." Request Form „ G DC] Account Number:_ 00 a— F (ifepplicable) •' To; COWa Division of Criminal Investigation From: City of Iowa City Support Operations Bureau,1s'Floor City Clerk's Office __— 215 E.7th Street 410 E.Washington Street Des Moines,Iowa 50319 NS)275-604a low..r'it, IA. C2240 (515)725-6080 Fax Phone: 319-356-5041 Fax: 31.9-356-5497 I am requesting an Iowa Criminal History Record Check on: _ Last Name (mendeloq•) FirstNameOmndmoy) Middle1d( Name(rctonnnended) A11\N.—NCI 4 V 1 u t�� h � �c 1 0\A c.k A„. to Datenof Birth (mm,dalcc�ly) \ Gendert (mandatary) �` Social Security Number(reeosumended) o l I�,o / \ -\� ` VI Male (Female 13 7?._ °\c:` , CA 6 I i. waiver information:Without a signed waiver from the subject of the request,a complete criminal history recordmaynot be releasable,per Cade of Iowa,Chapter 692,2.F'or complete criminal history record information,as allowed by late,always obtain a waiver signature from the subject of the request. — Waiver Release:Ihereby givepEliiiisron fT 'eabove requeliff edYIEMIi conduct an Iowa etinimal'liiitu,yrccordchad iV•ith'nmDi4lsionofCriminal inveniesrion(0e1). My criminal history data cone "me d,at is main me Ike DO may be released aa allowed by lent Waiver Signature; •-aAi -'" Iowa Criminal History Record Check Results Nc1 use 0,139 As of Cri' 3- (--1 , a search of the provided name and date of birth revealed: ArNo Iowa Criminal History Record found with DCI • ® Iowa Criminal History Record attached,DCI # DCI initials cif • DCI-77(08/25/10) ^_,w — Received Time Jul. 31. 2017 10:37AM No. 3782