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Home My WebLink About12-153CITY OF IOWA CITY 410 East Washington Street Iowa Cit I � 52240-1826 356-5040 1 $26 kJ I 9) 356-5497 FAX Authorization Number APPLICATION FOR TAXI DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.) First Middle Last 1. Name P(_saaa�� Ugrouti\ ��Wwv] 2. Mailing Address 10\l 90 co raw ikke f1 '3 as u 3. Telephone: Home 4. Prior experience in transportation of passengers: Other: Ce/%- 3tP,-U-1I - SISI 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When a-�s3 (Office Use Only) 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? Type of Offense A/0 Where 7. Have you been convicted of any traffic offenses in the last five years? Tvpe of offense /L/ 0 Where When When 8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? 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) Aj 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) The re- port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli- cation. (OVER FOR REQUIRED SIGNATURE AND NOTARY) der'N idrivbadg tr_ftd -LCL I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number. �/.Z # Af 7997 . I understand that if I falsely answer any questions in this application, that this application may be denied. I understand that if I falsely answer any of the questions in this application, that this application will 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 a license 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) A Signature of 3`` bt,ow STATE OF IOWA ) COUNTY OF JOHNSON Subscribed and swom to before me by M% I-2,�)\ 2 / GWYNh1KTV FFER \ NOTARIAL SEAL TATE OF IOWA 1 COMMISSIO161.1I R 760025 MY COMMISSION EXPIRES q ALSadd��On this day o rpt®� �� 1 � 0 '? 13 14 I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter- mined that there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code). -Signatur6 of Police Chief or designee Signiature of City Clerk or designee y- 7-/ z— Date y -/7- i a� Date NOT VALID UNTIL Police Chief and City Clerk have approved and authorized taxi driver names placed on the city website at icgov.org. Taxi cab businesses are required to provide Driver Identification cards. ***11f11f111ff##k####.1*fe#*#1fHNlflff1f1f1111Mf1ff####*H**!*#1111!*11fHfff1f11Nf11fff#1111#M#ff######****##*******1f11f1*fYf1111ffif*'YY#ff Office Use Only Approved application ✓ DCI report 7% State certified driving record Z-- Website rWebsite update t/ danrtexlarrvbadWap 2010.a 09am 0 bIaol2 Jul.,31. 2012 4:15PM Div of Criminal Investigation d1T1. )V. IVII I:49rm City Werk - Lily OT lovra clty No.6462 P. 2/15 No -2646 P. 2 STATE OF IOWA y: Record + Isl '�IOWAi��1 J;° t I ,4 . 1 �, 1 1. Check Request Form DClAccountNuxaber:m To: Tows )Division of CtiminnllnVestigation Support Operations Bureau, V, Floor 215 X. 7'b Street MsMolnes,Towo 50319 (515)725-6066 (515)725-6000 Fax I atn re uestln art%wa Criminal Histoi Record Check on: From: CTT'Y OF IO WA CITY CITY CLERK'S OFF)ICT 410 k. WASMXGTON STRMT IOWA CITY IOWA 52240 Phalle: 319-35(F-5041 Fax: 319.356-5497 T,ast Name(mondelory) MITt Xame nondate) 1V iddlo Nam (recommende Cl6ewaj !7 tsacld i llar'e'tw Date of Birth Nandatoo gender (mandatory) Security Number rceommwrded) Dlloil 1972 1VIale ❑femaleG' Tgo;dal °5�' Waiver. Information" Without a signed Vyaiver from the subject of the request, a complete crIminal history record may not be releasable, per Coda of Iowa,. Chapter 692,2, For complete criminal history record Information, as ullowed bylaw, always Watber �eYeaSe; IherebyglYo pernrissiort forfho s6oya f/ApICSting official to mnduUlJllnu'a ubninol hhtory rergrd eherkwlUtihe Division of Criminal IW31(84110n (DCI). Any Wndnal Wooly dale wncemingme that is mofnlainu( by tho DCI may be rdcavcd a allowed bylaw. Waiver ,Iowa, Criminal History Record Check Raylts (DCTbie only) As of �� a search of the proylded name and date o£birth revealed: ' v2rNo Iowa Criminal History Record fournd with DCT 13 Iowa Criminal HistoxyRecord attached, DCT # :. f � ACX initials_ 'eceived-TimeTJul, 30,1Q012 2:45PM No. 0465 — — — — — — — AC Iowa Department of Transportation Office of Driver Services (GII Flee) 800332-1121 PO Box 9204, Des Moines, IA 503D6-9204 515-244-9124 OFAX: 515-239-1837 Certified Abstract of Driving Record Inquiry Date: 6/16/2012 DL/ID #: 426AF7897(IA) Name: Miriasiel Elsemeih, Alsaddig Class: D Haroun Address: 1017 20TH AVE Audit #: 5986914 Issue Date: 05/17/2012 City/State: CORALVILLE, IA 522411342 Expiration Date: 01/01/2015 Endorsements: 3 Mailing Address: 1017 20TH AVE Restrictions: NONE Date of Birth: 1/1/1972 Mailing City/State: CORALVILLE, IA 522411342 Sex: M History Information CLEAR DRIVING RECORD Name: Miriasiel Elsemeih, Alsaddig Haroun DL/ID: 426AF7897 Customer #: 5615005 ID Status: None DL Status: VAL CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: Office of Driver Services Pursuant to Iowa Code §321.10, I, Kim Snook, 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: ......... 6/16/2012 IOWA'- D. 0. T..'Ps yf """. S = Office of Driver Services ^Q ��—'` Iowa Department of Transportation Name: Mirlasiel Elsemeih, Alsaddig Haroun DL/ID: 426AF7897