HomeMy WebLinkAbout18-020IDENTIFICATION NO. / 2? C;>
l 1 (Office Use Only)
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
(3 19) 356-5497 FAX
First � 1 Middle Last
1. Name (REQUIRED) S Q t �c(ld (yl QV) I LI rel 71-62wW1 ✓0
2. Address (REQUIRED) 2- 4,n I NJ 4jb 9 C I DW A C1 )-G I !s-�2L4i
3. Contact Information (REQUIRED) Email: e6t Wlg i 14:41MPhone: 3\a
(All written communicaiion sent via email)
4a. Driver's License expiration date (REQUIRED) 0 / I2> f G
b. Taxicab Business Name (REQUIRED) C ' 1; lA c7 A Y,
v � p
5. Prior experience in transportation of passengers: SL�1 P [AY
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? V\j o —
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?
TvDeofoffense Where When
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? W4:2
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)
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
/ 1 APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify pth�at�-I-rh�a�ve issued to me by the Iowa Department of Transportation a v lid Driver's license number
(� 22 W f{ issued on bf f 2 ' �1 zS piring on 1 1'�1y
2. I understand that if I
falsely answer any questions in this application, that this app icatl -ion 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 Date OZ 6 h s
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by �]r. �ulcQ n . J- aro k- atk on this / L -e day of
Ce W,. I — r.. -7,-A
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 ers se or -13 ZaZO
97
Signa a of Police 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.
Signature of City Clerk or designee
Date
NNY'+f1f}fflf 11f 111lNNNNl11fNlNNNINl1Nf 11f1f11N!llflNflllfMlNf+Yfltlf 1lkNfN+f f111ff f fNIi+NRflN+l+Mi+*'k 1+1f#OI'1fNfffNflNf
Office Use Only
Approved application
DCI report
State certified driving record
Website update
CleM AXIDRMW)GEAPPL9201C ffwrded.DOC 07/2016
1-eb,13. 2018 8:24AM Div of Criminal Investigation
Fro M:Gl[y of Iewb Olty Cloak dr/lob 3,a 3666007
No. 3594 P. 3
02/72/20 6 11:03 arose P.002/002
STATE OF IOWA
Criminal Ristory Record Check
Request Form
To: Iowa Division of Criminal Investigation
Support Operations Bureau, V Floor
215 E. 7" Street
Des Moines, Iowa $0319
(515)725.6066
(515) 125.6080 Fax
Ml Account Number: O D
(ifappheehte
From: City oflowa City
City Clerk's Office
410 E. Washington Street
Iowa City, IA 52240
phone: 319.3565041
. Fax: 319356.5497
1 ntn requesting an Iowa t..nnatuaanwa-•
Last Name (tnandatc)
--n.—,
11rSt Name (mmndalery)
Middle Name oaoamleltacd)
Date of Birth (majndalon)
Gender (mandalory)
Social Security Number recommeenndedd))
6 0
RM, ale ❑Ferrate
1 � > — �j� i7 — 1'{ � `? b
Waiver Information: 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, For complete criminal history record Information, as allowed by law, always
obtain a waiver signature from the subject of the request.
c:•
WajVer IteieaSe: I hucby give ptunbsion lbr the above «Qlksllnit official to conductm Iowa criminal hlstoly record chock with eh'c.�ivision ofCliminel
7-1
InvestigalionlDCq. Any elirninal history dole concening mo that is malmoinca by the DCl may be released.. d10aved by law:- rn
µ�/I�`
Waiver Signature: -
Iowa Criminal History Record Check Results;;; r.. (UC1L�eanty)
CD
As of� 3 I a search of the provided name and date of birth revealed: —
9 No Iowa Criminal History Record found with DCI
❑ Iowa Criminal History Record TtahACI #
DCI initials—
DCI-77 (08/25/10)
f
Iowa Department of Transportation
aeoe a6 omRrsetvices {roll Five) MP.02.1121
Po Bax 3294, nes manes, iA smixi; 924 515-244-3124
FA>C 515.2394837
History Information
Convictions
Citation Date Conviction Date
Certified Abstract of Driving Record
Explanation
Inquiry Date:
2/15/2018
DL/ID #:
422AF7170(IA)
Customer #:
5609235
Name:
Ibrahim, Saifaldin
Class:
D
ID Status:
None
Omarab
zone
Address:
2401 BARTELT RD
Audit #:
8788773
DL Status:
VAL
APT 2C
Issue Date:
01/23/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
05/13/2020
CDL Cert Status:
None
522462701
Endorsements:
Chauffeur
CDL Med Status:
None
Mailing Address:
2401 BARTELT RD
Restrictions:
NONE
Restriction
None
APT 2C
Supplement:
Date of Birth:
05/13/1960
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522462701
History Information
Convictions
Citation Date Conviction Date
ACD
Explanation
1county
IUR
09/08/2016 09/13/2016
S92
Speed (10 mph &
Tama
IA
under In 35-55 mph
zone
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Name: Ibrahim, Saifaldin Omarab DL/ID: 422AF7170
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:
2/15/2018
Name: Ibrahim, Saifaldin Omarab DL/ID: 422AF7170
Office of Driver Services
Iowa Department of Transporation