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Home My WebLink About18-048� r 1 VIII I ftr CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319)356-5040 (319) 356-5497 FAX Last 1. Name (REQUIRED) _ 2. Address (REQUIRED) _ IDENTIFICATION NO. ' 9 - O Li S' (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 First Middle �cyv\:-�- lS 3. Contact Information (REQUIRED) Email: -gamiY `'�9'2v ju Aue-ta%GellPhone: a1� 4-:2 ! 1113 (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) ��; z / n 2 b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: din a {S 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsvoere? �j Type of offense r9 Where ` end T' -1 V o a S IE 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? V l)A, Type of offense What happened to the charge? (Circle one) Where 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? a l U 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) NIA 04/2018 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 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). I hereby t teff th I have issued to me by the Iowa Department of Transportation a valid Drivers license number '9 : 0 n % issued on \ \�;3expiring on I �,c, 12, . I understand that if I falsely answer any ques io s 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"otary Public) Signature of Applicant - Date &, 0 -�� D n :4r- rn STATE OF IOWA ) COUNTY OF JOHNSON ) co Subscribed and sworn to before me by S r. u r L . ) , on this L, day of Aj, r. I --,- 1-11k _ 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 d of e ' icense a � Gy -Z7-/8 nature 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. or designee Office Use Only Approved application DCI report State certified driving record Website update Date aewrnxJMNIIADGEAPPLM18a�.DOC 04/2018 Vi VI IIIIIIIeI 111 y CS l lgdl 1011 at er� No, 9341 P. 3/3 04/17/2018 14:6c 8479 P.002/002 STATE OF IOWACriminal 1 a r Check 4) Requ To: Iowa Division or criminal Investigation Support operations Bureau, It, Floor 215 E. 7'a Sheet Des Mines, Iowa 50319 (515) 725.6066 (515)725.6000 Fax V on: SGtv.:i DCI Account Nwnber: (if epplirable) From: City of Iowa Cil Clty Clerk's Orme, 410);, Washin ton9treef Iowa City, IA 52240 Phone: 319.356.5041 Fax: 319.356-5497 .n D k 04 9 < 1 RMale ❑Female 6 _ Is v beWaiver rel a sIble, per Code: flo%vaut a signed waiver[rom 1118 subject of the request, a complete criminal hisfory record may not be releasable, per Cade oflowa, Chapter 692,2. Foreomplete erlminal history record Information, as allowed bylaw, always obtain a waiver slgria fore from the subject of the request, Waiver Release:I hereby give permission for the above «quisling official to conduct an Iowa erlminal l�isloryrecord check with Iheoivision oPCriminxl Lavesliion (DCI). Any gmcriminal historydale concemin4 melLal iamaintahred by[W)Clmeybereleesed wallowed bylaw, As of Waiver a search of the provided name and date of birch revealed: e* No Iowa Criminal History Record found with DCI IJ Iowa Criminal History Record alta had, DCI DCl initials DCI -77 (08/25/10) Received Time Apr, 17. 2016 2:14PM No, 1511 E 5N ,RTER I ShMPLER i CUSia,AiER DRIVEN Mw,iowadotgoy Driver & 1dentificaiion selviGes pt? E r Z I Des freines. IA 50 t PrCne 5;r IZI4.912.4I FaX 515 -23A -;W Certified Abstract of Driving Record Inquiry Date: 4/26/2018 DL/ID #: 266AD7808 (IA) Customer #: 5429309 Name: Ali, Samir Class: D ID Status: None Isameldein Address: 2427 BARTELT RD Audit #: 7504999 DL Status: VAL APT 2B Issue Date: 11/06/2013 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 11/03/2018 CDL Cert Status: None 522462710 Endorsements: Chauffeur 3 CDL Med Status: None Mailing Address: 2427 BARTELT RD Restrictions: NONE Restriction None APT 213 Supplement: Date of Birth: 11/03/1985 Mailing IOWA CITY, IA Sex: M City/State: 522462710 History Information CLEAR DRIVING RECORD Name: Ali, Samir Isameldein DL/ID: 266AD7808 Pursuant to Iowa Code §321.10, I, Darcy Doty, Director of Driver & Identification Services, Iowa Department of Transportation, do hereby certify that I am the custodian of the records held by Driver & Identification 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: Name: Ali, Samir Isameldein DL/ID: 266AD7808 4/26/2018 Driver & Identification Services Iowa Department of Transporation