HomeMy WebLinkAbout17-130 • IDENTIFICATION NO. I'7 13
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CITY OF IOWA CITY APPLICATION FOR TAXICAB/MOTORIZED PEDICAB VEHICLE DRIVER
(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 ���/, a�t
1. Name(REQUIRED) yo
C.I 5(^ A6 p r-Cic Q�
2. Address(REQUIRED) r�4 7 / ..f )r) 11-P r)1
3. Contact Information(REQUIRED) Email: 7' 2C.- s i - r-Yi Cell Phone: 706 25 9/(DS
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) ok ( o \ I '7 .� 5
b. Taxicab Business Name(REQUIRED) (
re: C TgAi
5. Prior experience in transportation of passengers: y vC
6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? A/c)
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? 4((;
Type of offense Where When
What happened to the charge?(Circle one) a
Convicted Dismissed Deferred Suspended Plead Guilty%?,Otlir
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8. Has your driver's license or chauffeur's license been suspended or revoked in the last five eafir ? ' -)
Type of offense Where —Wen-'
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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
44
4 , 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
7-b icl t-!SBS 7 issued on -/3o(/7-- expiring on n /„)/I7_a 2r . 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 provision-itttr5-Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant /on ��/ Date q/'/5// f
STATE OF IOWA )
COUNTY OF JOHNSON ) r
Subscribe, and sworn to before me by y,,,,,,,-1. r . A Dc1 1)IHIizron this / day of
Fjas'momNoary Public in - '41 for the State of I. .
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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 City of Iowa City(Title 5, Chapter 2, City Code).
Expiration date of Driver's license D ( /v( /-2-02--
(17511-47v2 //-5/12-°1 7
ig ature of Po ice 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.
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Sig ature of City Clerk o esignee
4 Date 74 -1:7
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***********************************************************************************************************.* �** **********
Office Use Only > CA) .
Approved application
DCI report
State certified driving record
Website update
ClerkfTAXIDRIVBADGEAPPL92014arnended.DOC 07/2016
Page 1 of 2
GIOWA DOT
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 9/15/2017 DL/ID #: 210AN5857 (IA) CDL Permit Class: None
Date:
Customer 6676382 Class: D CDL Permit Issue None
#: Date:
Name: Abdalla Omer, Yousif Audit#: 2105981 CDL Permit None
Fadlaiseed Expiration Date:
Address: 2604 BARTELT RD APT Issue Date: 08/30/2017 CDL Permit None
2A Endorsements:
Expiration 01/01/2025 CDL Permit None
Date: Restrictions:
City/State: IOWA CITY, IA Endorsements: Chauffeur 2 ID Status: None
522462728
Mailing 2604 BARTELT RD APT Restrictions: NONE DL Status: VAL
Address: 2A Restriction None CDL Status: None
Mailing IOWA CITY, IA Supplement: CDL Permit ELG
City/State: 522462728 Status:
Date of 1/1/1973 CDL Cert Status: None
Birth:
Sex: M CDL Med Status: None
History Information
CLEAR DRIVING RECORD
Name: Abdalla Omer,Yousif Fadlalseed DL/ID: 210AN5857 (IA)
Pursuant to Iowa Code §321,10, I, Melissa Spiegel, Director of Office of Driver Services, Iowa Department of, nsportation, do
hereby certify that I am the custodian of the records held by the Office of Driver Services, that this is a_true ari2Pbccurate copy of
an official record currently In the custody of said office, and that I have been authorized by the Directorf the Iewe Department of
Transportation to so certify. .---;7 c")
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In witness whereof, I have caused my signature and the seal of the Department to be set upon thisaa^nerrtrat Anrys Iowa
this date:
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�••,....,,.%" 9/15/2017 ^D
M4.4 IOWA 41;
Opire
D. O. T.;' i' P7`�� ir1
JrrrrOf•p•••'••� Office of Driver Services
Iowa Department of Transportation
Name:Abdalla Omer, Yousif Fadlalseed DL/ID: 210AN5857 (IA)
9/15/2017
Sep, 14. 2017 12:08PM Div of Criminal Investigation No. 1012 P. 6/8
From:c:lty of Iowa [Oily Claris thrice 310 3666497 00/11/2017' 16:,e 022o P.oO2/002
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-riVe—tlg4cf STATE OF IOWA
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. - Iowa ;1 � :; crrilt y e,co.rd Check ,,
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CC i quest Form
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DCI Account Nltntber: Cf DOD.
--- -- • —. _.__. _.—_ .--(if applicable) —-- -
To: lows:Division of Criminal investigation Front: City of Iowa CIE
Support Operations Bureau:, 1A')Moor r --,»w..._..—._ ._ ..._
City Clark's Office
215 E,711'Street 410 E.WAshin;tori Street
Des Moines,Iowa 50319 — — -- --- --•—
(515)725-6066 _ rIW,City, 1A-.52240
(515)775-6080 Fax .• ______
Phone: 319-356-5041_
Fax: 319-356-5497
I am requesting an Iowa Criminal History Record Check on;
Last Name (mandatory) —'— --�--- ._.
( ry') .First Nan-ie(mandatory) Middle Name(recommended)
Abhit'L' 1, (9-)9.9v/-r you 5 (^ �
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Date of I firth(mandatory) Gender(mandatory) Social Security Number(recommended)
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Waiver information: Without a signed waiver from the subject of the request,a complete criminal history record may not
be releasable,per Code of Kowa,Chapter 692i.For complete_criminal history record information,as allowed by law,always
`obtain a waiver si>tnature from the subJect of the request.
Waiver Release-I n.r.t uapermission-1br-die-ebei g�rcsring-official to-conducraniurva i.rimTnallu DIrd dlieoic wn i theDivisi4 -iminaJ--
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Investigation(DCI). An'-criminal hiknry dafn(unup:Jy J', n.ar rk.:..1,:....r,,.O.e•Bei.......D•%..4.1........1,,,‘.1/..”...04 4)1.1%V. ••••-.1
i �. Cr,Waiver Signature, t - ►�'7
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Iowa_Cr•irr thai HistorL Record Cheek Results m
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As of �—!Li—i 7a search of the provided name and date of birth revBaled: - • .;
No Iowa Criminal Ilistorl) Record found with DCI
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0 Iowa Criminal History Record attached, DCI ft •
DCI initials-___'
DCI.-77(08/25/10)
Received Time Sep, 11, 2017 2:53PM No. 6522