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HomeMy WebLinkAbout17-101 f , +11 IDENTIFICATION NO. / _) - /o1 t (Office Use Only) ��ZA'ma Arab, III .... ameciti PIT 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 Last• 1. Name (REQUIRED) IWINeNI ` ^ 4_ c4 _- K1�� 2. Address (REQUIRED) �3 C r y p c) r( /o - Lf 1191 c--2_2_11 / V....0%3. Contact Information (REQUIRED) Email: � vv\e.l 1✓' A as a )'S-4•u'Cell Phone: 3/9--..r/Z.. n y (All written communication sen via email) 4a. Driver's License expiration date (REQUIRED) d/• o/- 2.0/ 9 b. Taxicab Business Name (REQUIRED) 1 to pct v� T i2G �U� 5. Prior experience in transportation of passengers: 43 �Pwy S 6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? NO Type of offense Where When 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? Type of offense Where When oi„sy 'l L ,s,p. �d�,,.3 •- �f fy Lf- 21 .4,4L Av .„, G lock, 4! c'2 -off •20/1 What happened to the charge?(Circle one) CE-onvil 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?al N w7 Type of offense Where 5 W herr-' -7a• AlPr — C, rri n-t r- 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pt�Op ale t nam /\/v w � Q 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 �6'( K g4 issued on 6 P .62•24expiring on a(• 01.)1U 5 . 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, 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 '- 9 Date O8 07 ' 2017- ************************ ***************************** ******************************************************************************* STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by )(to", I H- . j) CL on this -7 day of fit' 7011. WENDY S.MAYER _ I _ i`A • .mmission Number 729428 Notary Public in .y. for the State of low-4i , c' r V ****** ************* *********** ****iririr** nlr******* 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). Expiration date of Driver's license / /( (2J1 ' Signature of Police Chief 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. ,( ig ature of City Cler r designee Date ***********************************M******************* ***************************************** **************A A Ai A A A**** Office Use Only c 1 'T1 C Approved application *won 330 DCI report c1-4 � r State certified driving record j Website update : fn z yc O OerVTAXIDRIVBADcEAPPL92014amended.Doc 07/2016 Aug. 4. 2017 12:38PM Div of Criminal Investigation No. 4211 P. 1 P rc.,,:.,.,,y u, ,V wer �.u,y Clerk v,i icoe . IW oono4vi Oe/O1/2017 08:6.e .7144 r.u02/002 • /4:K�.L�,, STATE O.4' IOWA . . 1 - „: },' ?awn '. Criminal History Record Cheek ' !.,.,r.,,..:::::, '� ;Kr \� Request if Farm - - `. DC) Account Number: `c0 0.--F- (iiepplicable) -- • To: Iowa Division of Criminal investigation ):turn: Eit�,of lows City Support Operations Bureau, f"Floor City Clerk's Office 215 E.7'h Street 410 E.Washington Street Des Moines,Iowa 50319 ---- ________ 4 725-6066 — .14waf1134_IA _`7240 (515)725-6080 Fax --- Phone: 319-356-5041 Fax: 319,-356-5497 I am requesting an Iowa Criminal 1-11591 'Record Check on: Last Name (mandatory) FfrName (mandatory) Middle Name(recommended) u st I< I (JA < i '1IL HiAssTr\-/ Date of Birth (mandator•) ,..Gender(mandatory) Social Security Number(reeonnended) 6!. D/ ( ! 734 Male ❑?+'emale e / / -1 - g 1-� Waiver Information: 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 si nature'Yom the subject of the re crest. Waiver Release;1 hereby give permission for the above agues ting•off cial-to conduce-an-lowa-crisninaI-hj tory record checinvith-tbe'DtvisiosrofCriatinal—'----— invesugation(DCI), Any criminal history data concerning me I al is maintained by the DCI may be released 'lowed by i3w. r- fYaiver Signature:`-_ • __ vim..-_: . . .; . vt Nil Iowa Criminal Ilistory_Ityka Check Results (oc,use only) As of (26-, 9'- (' , a search of the provided name and date of birth revealed: ' 4co r•-r"4-14 No Iowa Criminal History Record found with DCI ..,::, n I r o Iowa Criminal History Record attached, DCI # .2_, M f, • rel, -v DCl initials w DO-77(08/2S/10) Received Time Aug, 1. 2017 8:26AM No. 3832 tizio SMARTER I SIMPLER I CUSTOMER DRIVEN WWW'IOWadot.gov Office of Driver Services PO Box 9204 I Des Moines.IA 50306-9204 Phone:515-244-9124 1800-532-1121 I Fax:515-239-1837 www.iowadot.gov Certified Abstract of Driving Record Inquiry Date: 5/31/2017 DL/ID#: 809AK8656(IA) CDL Permit Class: None Customer#: 6227659 Class: D CDL Permit Issue Date: None Name: Kirja,Kamil Hassan Audit#: 9403765 CDL Permit Expiration None Date: Address: 1913 GRYN DR Issue Date: 09/08/2015 CDL Permit None Endorsements: Expiration Date: 01/01/2019 CDL Permit Restrictions: None City/State: IOWA CITY,IA 522464408 Endorsements: 2 ID Status: None Mailing Address: 1913 GRYN DR Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Mailing IOWA CITY,IA 522464408 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 1/1/1975 CDL Cert Status: None Sex: M CDL Med Status: None History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 03/17/2015 ;04/21/2015 M14 Fall to Obey Traffic Sign/Signal Johnson IA 11/25/2016 ,02/07/2017 M14 Fall to Obey Traffic Sign/Signal Johnson IA Name:Kirja,Kamll Hassan DL/ID:809AK8656 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: _®�1Ep1Clf pil s 'l:'•,,.... •V�r,� 5/31/2017 04": IOWA: ' lici D. O. T. z p7,E ,I , I% � ;i;wct, Office of Driver Services ry ili�f' _� 11hv�8R o—s Iowa Department of Transportation - ©atiQ _ 2 y Name:Kirja,Kamil Hassan DL/ID:809AK8656 30.--4 Cid owls rs gi [n 3 Q W