HomeMy WebLinkAbout17-136CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319)356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. 17— j3 6
(OfficeUse Only)
APPLICATION FOR TAXICAB I 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
Last
J S 1-
2. Address (REQUIRED) ia" M enr C4- LU Inlq r p t -ca - A S2� (a
3. Contact Information(REQUIRED) Email: Kact»1oy-)0-eVAV�a,ro�A CellPhone:33-5`1((P
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) 07/1V zo ( 8
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers: CC I _ f� m w i Cav rpt t
1
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? No
Type of offense Where _When o
0
What happened to the charge? (Circle one)
M
Convicted Dismissed Deferred Suspended Plead Guilty:" > baherS rQ
Have you been arrested / charged with any traffic offenses in the last five years? yes
Where
What happened to the charge? (Circle one)
When
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? N o
Type 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)
/J 0
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
r
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certi that��I[[SY have issued to me by the Iowa De a ent of Transportation a valid Driver's license number
7i3ii,i �issu03 0 o(3expiring on nLR . 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 +t'*— Date N103 / / I
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STATE OF IOWA )
COUNTY OF JOHNSON > l�grnr� l 1 H d ►+5+ a F
S an sworn to before me by n this day 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 City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Driver's license ://S / 0
d 3 zo Os1k—
Signatur�olice Chief or designee
b1-S/ZA 7
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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Signal re of City Clerk r esignee Dat
Office Use Only
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a
Approved application
,yam`—may
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DCI report
7-<
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State certified driving record
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07/2016
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CiJiUWADOT www.iowadot.gov
SMARTER I SIMPLER I CUSTOMER DRIVEN
Office of Driver Services
PO Box 9204 1 Des Moines, 1A 50306-9204
Phone: 515-244-9124 1 80D-532-1121 I Fax: 515-239-1837
www.iowadot. gov
Inquiry
Date:
Customer
Name:
Certified Abstract of Driving Record
9/22/2017 DL/ID #: 733A79154 (IA) CDL Permit Class: None
6142527 Class: D
Mustafa, Kamall Eldien Audit #: 1661090
Address: 27 LEAMER CT
City/State: IOWA CITY, IA
522463229
Mailing 27 LEAMER CT
Address:
Mailing IOWA CITY, IA
City/State: 522463229
Date of 9/18/1975
Birth:
Sex: M
Convictions
Issue Date: 03/08/2017
Expiration 09/18/2018
Date:
Endorsements: Chauffeur 3
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Restriction None
CDL Permit
None
Endorsements:
CDL Permit
CDL Permit
None
Restrictions:
)ohnson
ID Status:
None
Restrictions: NONE
DL Status:
VAL
Restriction None
CDL Status:
None
Supplement:
CDL Permit
ELG
Speed
Status:
)ohnson
10/05/2014
CDL Cert status:
None
,Speed
CDL Med Status:
None
History Information
Citation Date
Conviction Date
ACD
Explanation
]UR
County
05/23/2014
'09/04/2014
S92
Speed
'IA
)ohnson
10/05/2014
10/16/2014
,S92
,Speed
,IA
Johnson
Name: Mustafa, Kamall Eldien DL/ID: 733A)9154 (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:
IOWA °
D. 0.
9/22/2017
�f 09IVEN��`
Office of Driver Services
I
Sep, 29. 2011 1:40PM Div of Criminal Investigation No,2366 P. 9/9
Ff."n�....�.> .". Clam aIw �c aM�Wa 09/00/2017 11:69 #240 P.002/002
TATE GFIG-WA
1
CHLI'llinal History Reco d Check
\ RegUest ]i•orkilli
I'D: IOM Division of Criminal Investigation
Support Operations tiurentl, I'I Floor
215 E. 7" Street
Des Moines, )DIVA 50319
(515)72S•6066
(515) 725-6080 Fax
am
,INAOS"
Iowa
First Name
KA Vnel,R
DCl Account Nolnber; _. Q L pi::
Ruppllcable)
From: City Of Iowa City
City Clerk's Office
4)0 E. washing(oh Street
lova C)ty IA 52240
Phone: 319-356.5041
Fax: 319-356-5497
El j. i -ems
are 00r Birth (/mandatory) ends • ,andarn ) SooinI �'eo/u'rih' Nvauboa• trccy
o'71) d (� �� ®Male ❑Female c2�� (D ��CK 67
waiver injormanoll. 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.I~or corn Tele criminal history mcord IllfermatlOn, as allowed by law, always
obtain a waiver signature from the subject of the reauest.
Wal ver BeleR9e; i hertby glye petruklion for (he above requesliog off cin! to conduct an lova uimind historyrecord cbcck wllh Ihel)lvision of Criminal
Inresaga(iol(DC)). Any criminal hislory dela concerning m dlalis snalnlained by thelsClmeybereleasedasallowed bylaw.
Maiver Signature: p
Iowa Criminal Histor Record Cileck Results y)
ll11 (0C1 sae only)
As of -1 a T7a search of the provided name and date ofbirthrevealed:
11 No Iowa Criminal Histoly Record found with TXI
❑ Iowa Criminal History Record attached, DCI #
DCIjsutials'�..
DCI -77 (08/25110)
Received Time Sep -20. 2017 11:32AM No.7627