HomeMy WebLinkAbout17-139I IDENTIFICATION NO. -7 ` j 3 9
(Office Use Only)
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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 S2240-1826 Failure to complete the "required" information will resuk in denial of the application
(3 19) 356-5040
(319) 356-5497 FAX
First Mid le Last
1. Name (REQUIRED)
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2. Address (REQUIRED) V �vf `, C-ZJ 4` 1�
3. Contact Information (REQUIRED) Email: Or1P,r FL,. z FPhone: '10t_>-i7[,�_ k7
(All written communica ion sent via email)
4a. Driver's License expiration date (REQUIRED) /01// 6/2f5 �
b. Taxicab Business Name (REQUIRED) � cQ
5. Prior experience in transportation of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere
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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? Yep
OlG
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(Circle one) \ to
Convicted Dismissed
Where
J�nrtav` cam
Deferred Suspended
When
Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /44
Type of offense
Where
When
9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please jiroutde Q name s A/D
CA r
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT€'CER4IEDm
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE I EtlEF 4VIEWO
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
I/ ,
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transpo atio a valid Driver's license number
issued on o 5 expiring on � I understand that if I
falsely ans er a y uesti sin 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
22, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant_ /J� 1J ��y�lC �G Date-� �,—( o j
STATE OF IOWA
COUNTY OF JOHNSON
Subscribed and sworn ti
I—
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).
.16Z C/
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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.
Sign re of City Clerk or dtWignee 'Date
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Office Use Only
Approved application
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DCI report
State certified driving record
Website update `
CIerdTAXIDRNBADGEAPPL92014 m med.DOC
07/2016
Fr1'e''1. tvI ,,,IV-Jt,Cr arvi v vi V IIII 1 iix - _r ii vc a L 1 e a t i V 1
06/10/2017 12:L"2' 0"7117(". I/ L).c,2
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Criminal History Record Cheek '• �x>
Request Form
Wtinssy
DO Account Humber: _ 1+0 n a- - (--
(if Opplienb1c)
`(ifOpplienb1c)
To: Iowa Division of Criminal Investigation Front: City o€Iowa C&_
support Operatimss liureall, 1" Floor City Clerh's Office
215 E. 7i' Street 410 E. Washn Street
Des iVlohtes, lava 50319 '-
k515) 145-61065 Iowa tty, IA 51240__
(515) 925-6080 Fax_
Phone: 319-356-5041
Fax: 319-356-5497
18 111 1eauestinn on lnwa Cr6n'u,A1 9ietniv P.,n.-0 rI,.nL
Last Name (mandatory)
First Name lmandatory)
T'fiddle Name (recommended)
S'al� �,
��e+r
&Z
Date of Birth (ma,rdwory)
Gender mandatory)
-
Social Securit Number aecmmended)
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LIA4ale QFetnale
220 —Fig' �rJ2'7
Weller rrffarotati0/t: Without a slgoed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code of lows, Chapter 692,2, For complete criminal history record information, as allowed bylaw, always
ohtain a waiver Signature from the subject of the request.
diver Release; 1 hereby give permission for the above regmWal; official to conduct an Iowa criminal histary record caeok with the Division orCiintinal
Invuligatiols (DCI). My criminal history dela coneeming me dial is malnmined by the DCI maybe released as allowed bylaw.
N�aiverSigrtafure: v .��
Iowa Criminal History Record Check Results (DO UPC ony)
As of _ ' a starch of the provided name and date of birth revealed:
No Iowa Crilninal History Record found with DCI ._
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❑ Iowa Criminal History Record attached, DCT # ' -1 --4
DC] initialss`M
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Received Time Aug. 10. 2017 12:13PN No. 4604 '
ARTS
100=1 DOT
SMARTER I SIMPLER I CUSTOMER DRIVEN vvww.lowadogov
Inquiry 10/5/2017
Date:
Customer 5868786
Name: Salih, Omer Elhaj
Page I of 2
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-91241800-532-11211 Fax: 515-239-1837
www.iowadol.gov
Certified Abstract of Driving Record
DL/ID #: 545AGO871 (IA) CDL Permit Class: None
Class: D
Audit #: 1011345
Address: 1637 ABER AVE APT 2 Issue Date: 05/17/2016
City/State: IOWA CITY, IA
522464728
Mailing PO BOX 452
Address:
Mailing IOWA CIN, IA
City/State: 522440452
Date of 10/15/1967
Birth:
Sex: M
Convictions
Expiration 10/15/2021
Date:
Endorsements: Chauffeur 3
Restrictions: NONE
Restriction None
Supplement:
History Information
CDL Permit Issue
Date:
CDL Permit
Expiration Date:
CDL Permit
Endorsements:
CDL Permit
Restrictions:
ID Status:
DL Status:
CDL Status:
CDL Permit
Status:
CDL Cert Status:
CDL Med Status:
None
None
None
None
None
VAL
None
ELG
None
None
Citation Date
Conviction Date
ACD
Explanation
JUR
County
03/03/2013
03/25/2013
S92
Speed
IA
Johnson
07/09/2013
08/23/2013
S92
Speed
IA
Johnson
11/21/2015
01/05/2016
M08
Fail to Obey Officer
IA
Johnson
Name: Salih, Omer Elhaj DL/ID: 545AGO871 (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 tPdr31owa 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 '9ecum.&At, at AvWgny, Iowa
this date:
L
10/5/2017 -.-..
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http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 10/5/2017
". 14 V
Name: Salih, Omer Elha) DL/ID: 54SAGO871 (IA)
Page 2 of 2
Office of Driver Services
Iowa Department of Transportation
http://172.29.254.55/drivers/reports/customerhistorylcertifieddrivingrecord.aspx 10/5/2017
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http://172.29.254.55/drivers/reports/customerhistorylcertifieddrivingrecord.aspx 10/5/2017