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HomeMy WebLinkAbout17-138it"III � Mlw®r�11 CITY OF IOWA CITY 410 East Washington 51reel Iowa City, Iowa 52240-1826 (319)356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED IDENTIFICATION NO. %%— 13tO,_ (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 result in denial of the application 3. Contact Information (REQUIRED) Email: a+ 4: . c%kb& oat-7o4DG N -,(x L -(-01-Cell Phone: 31 9 4541 2% 23 (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED/) O —4 / P(OS 2� I b. Taxicab Business Name (REQUIRED) (^a 1< j Cu YJ I 5. Prior experience in transportation of passengers: . \ nk,z, . �'cK; C aL, UO i tzw YdstS Cu�, For 3 ic>AVS 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? /VL)— 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 Where When 215iLl i S02(2d 2cp(c:; Tr hL&-,b,Tot a i� 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? f(/o Type of offense Where When 9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please prt v 0q the,gameW (YCD n Tj --r DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE.,C'�2TIFIED r DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE 611E Rr;YIEWin You must apply for an individual Department of Criminal Investigation Report (form available upa req�t). .r— (SECOND (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number e--( l ou(11 issued on 6�Io3/ t- expiring on o-Ijos 1 2oI6. 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 ApplicantDate q 107 STATE OF IOWA COUNTY OF JOHNSON 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 l 1`'0))-- Signature of Police Chief or designee i o/sly 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. Signat re of City Clerk or6osignee Datji Office Use Only Approved application DCI report State certified driving record Website update b � R; CD -t C7 CJt rn A 0 a Derk/T"DRN9ADGEAW'L92014am ded.DOC 07/2016 ARTS Page I of 2 C1J10WADGT wvvw,iowadot.gov SMARTER I SIMPLER I CUSTOMER DRIVEN Inquiry Date: Customer Name: Address: City/State: Mailing Address: Mailing City/State: Date of Birth: Sex: 10/5/2017 6068081 Office of Driver Services PO Box 9204 1 Des Moines, IA 50306A204 Phone: 515-2449124 800-532-1121 I Fax: 515-239-1837 www.iowadol.gov Certified Abstract of Driving Record DL/ID #: 673A]0477 (IA) CDL Permit Class: None Class: A Ibrahim, Amin Mohamed Audit #: 1651063 Adam CDL Permit None 2420 BARTELT RD APT Issue Date: 03/03/2017 2C Restrictions: 'IA ID Status: Expiration 04/05/2018 Advanced Practice Nurse Date: 01/27/2017 IOWA CITY, IA Endorsements: Tank, Double/Triple 522462707 09/24/2015 Trailers 2420 BARTELT RD APT Restrictions: NONE 2C Restriction None IOWA CITY, IA Supplement: ' ='� 522462707 J n 08/27/2017 4/5/1968 Improper Registration I& CDL Medical Examiner's Certificate CDL Permit Issue None Date: CDL Permit None Expiration Date: Carly CDL Permit None Endorsements: A329749 CDL Permit None Restrictions: 'IA ID Status: None DL Status: VAL CDL Status: VAL CDL Permit ELG Status: CDL Cert Status: Non -Excepted Interstate CDL Med Status: Certified Certificate Specifics Explanations Medical Examiner First Name Carly Medical Examiner Last Name Roskop Medical Examiner License Number A329749 Medical Examiner National Registry Number 2081981498 Medical Examiner Jurisdiction 'IA Medical Examiner Phone (319) 377-5373 Medical Examiner Type Advanced Practice Nurse Medical Certificate Issued Date 01/27/2017 Medical Certificate Expiration Date 01/27/2019 Date Added to CDLIS Driving Record 03/03/2017 History Information -n_ J Convictions i7 ri Name: Ibrahim, Amin Mohamed Adam DL/ID: 673AJ0477 (IA) http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 10/5/2017 y Citation Date Conviction Date ACD Explanation ?--CFunty 06/18/2014 07/07/2014 S92 .Speed (10 mph & under in 35-55 mph zone)IA PotR9 09/20/2015 09/24/2015 S92 Speed Jtr n 12/19/2015 01/08/2016 M14 .Fail to Obey Traffic Sign/Signal' ' ='� Ig J n 08/27/2017 109/15/2017 Improper Registration IA' Johnson Name: Ibrahim, Amin Mohamed Adam DL/ID: 673AJ0477 (IA) http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 10/5/2017 ARTS Page 2 of 2 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. T. Name: Ibrahim, Amin Mohamed Adam DL/ID: 673A30477 (IA) 10/5/2017 Office of Driver Services Iowa Department of Transportation http:// 172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx N O OC-) .J C:) ■ �-� C r C-) m M o 10/5/2017 Uct. Z. 2U1/ 10:941RM Div of Criminal Investigation ' Fre nr.�.rq m r�wa ,-.uy ClBrra vniva aro a000.. esr N.09/26/2097 15:t,.248124. .002/002 STATE OF 10 -WA i Crit�lliulal History Rec, rd Check Request JForin To: Iowa Division of Criminal111vestlgation Support Upu•adonxlinreau,I" Flool 215 E. 7i' Street Des Moiues, Iowa 50319 (515) 725-6066 (515) 725-6080 Fax DClAccountNumber: (if apylicable) From: _City of Iowa City City Clerk's Offiee -- —"' 410 C. Washington Street lows C1ty, lA 52240 Phone: 319356.5041 Fax: 319-356-5497 – Iowa 1riminal History Recon d Check Results MCI use only) As of �— a search of the provided mule and date of bill revealed: 4�#o Iowa Criminal History Recoyd found with Del © Iowa Criminal History Record attached, DCI DCI initials DCI -77 (08/25/10) Received Time Sep, 28. 2017 3:08PM No, 7681 r cJ