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HomeMy WebLinkAbout14-205 Authorization Number —i05 r 1 (Office Use Only) ln.:11171tirialaiT MIM®I 11 APPLICATION FOR TAXI/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 52240-1826 Failure to complete the "required"information will result in denial of the application (3I9 356-5040 (319) 356-5497 FAX First A ,� � Middle Last \I.okuirj51. Name(REQUIRED) /�� ��11 .}— 2. Mailing Address(REQUIRED) ?� b B (-y, RD t 2 C r �0�d c-< "`((rA(J 2 1 3. Contact Information (REQUIRED) Email: a ��� co-a L r1 ell Phone: 47 4. Prior experience in transportation of passengers: (c - (�e 6C��C e� qF' +1/�Q;l( 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? / - Type of offense Where When 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol orar•ugs in the last five years? 12 i �,. Type of Offense Where Whet — ti N-)s,. rn 7. Have you been convicted of any traffic offenses in the last five years? Type of offense ` Where When ye 4i2e1 (10-l1 ti, 5tOtzaj 2—(1107,( yV « /2, 112 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Su '— ( Type of offense Where When it* \AAA 55)vi Tscuilist 1\11( 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). (OVER FOR REQUIRED SIGNATURE AND NOTARY) 09/2014 I hereby certify I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number S L( _ I( 9®:g . 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 p ovisigns of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) ` a r c� ,�f(� Signature of Applicant / �, I II ,� _ Date (Yl f7e' L_✓16f / ZO YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL L AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. STATE OF IOWA ) COUNTY OF JOHNSON ) 1- .�/- scribed and worn to before me by V) l p f a Yr-e — S. On this L' --day of `1/40'141,p KELLIE K.TUTTLE Notary Public in and for the State of Iowa ii c" My Com issi n Expires 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 • • t • •• City of Iowa City(Title 5,Chapter 2,City Code). Al r 0. , ��jL"/� y Sig atur: of Po ce hief or designee Date YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. eases 9//02/it Signa LW:71a);City Clerk or designee ate Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width)and 51/2" (height)and prominently displayed to all passengers. ...*.*.*.......**..*.**.**....****....*.*..*.***.*....***..........**.*****.***.*...****..**.**....*...**.....****..*.***..*****....*.....**.... Office Use Only Approved application DCI report State certified driving record Website update ClerkfTAXIDRNBADGEAPPL92014amended.DOC 09/2014 Sep. 11. 2014 12: 12PM Div of Criminal Investigation No. 0013 P. 1/7 Sep. J. /VILE 4: D/rlvi City Li erg — Lily 01 Iowa k, ity Nlu, Niru P. uc r ' • • , ukv STATE OF IOWAQt,0 , . Y6 �. s � ` ' .rlyaC , Z:). 'm f 4 ? Cr' YI Regiaegt For ;i �jy� OCT Account Number: LiUQp C (If applicable) To: ioWa Division of Criminal Investigation From: City of Iowa City • Support operations Bureau, tat Floor City CleW.s Office 21S E.76 Street 410 E.Washing-toil Street ©_ Des Mortes,Iowa 50319 3 (615)726.6066 Iowa City, IA S22i —7i, (315)725-6050 Farr • Phone: 319-356-5041 tv • 319-356-5497 rC� . Rax: x. a I am regUosting an Iowa Criminal History Record Check on: Last Name (mandatory) _ First Name(mandatory) Middle NIUg(rceommendcd) \ 6 Ai 0 kaAAL-e) - Date of Birth(mandefory) _ Gender(n,agtiatoty) Social Security Number(r ernntendcd) • D /5Y-I Gale OFemale 04 g 3662_ Waiver l"nforrnafio>`a:Without a signed waiver from the subject of the request,a complete criminal history record may not bo releasable,per Code of Iowa,Chapter 692,2.1'or complete criminal history record information,as allowed by Jaw,always obtain a waiversignafttre 1Vom the subject of the request, . • Waiver Release:I herby givo permission for the ebovc[questing Alois(to conduct an Iowa criminal Ills tory rceord cheek wish thoAivision of Crfminal • Investigation(DM, Any criminal Ulstory data caic.rnin3 me that is mointelned by the►j I day be released as allowed by law.` // l • Y7raiVerSignature: 4 �(y1\1 �.J�.o_.t U`-'l . � 0. 14...,.... , Iowa Criminal History'Record Check Resnf (DCI use only) As of • 9'4/.7 a search of the provided name and date of birth revealed: • t .t . 0 No Iowa Criminal History Record found with DCI ` 0 Iowa Criminal History Record attached,DCI# _ N • DCI initials 0 • n.,.. :„.a T :,,,.—.C... 1 —1014— 4• WM Ne hA ,M7--- To X01, . , ,yADfI b- -A- . (lAt _ I ( _ c... vvvvvv,lovvadotov SMARTER I SIMPLER I CUSTO IE DRI • ..... . Office of Driver Services PO Box 9204 I Des Moines,iA 50306-9204 Phone:51.5-244-9124 1800-532-1121 iFax:515-239-1837 www.io wadot.gov Certified Abstract off Driving Record Inquiry Date: 8/28/2014 DL/ID#: 542AG9038 (IA) Customer#: 5863128 Name: Khames, Mohamed Class: D ID Status: None Address: 2540 BARTELT RD APT Audit#: 7227307 DL Status: VAL 2C Issue Date: 08/09/2013 CDL Status: None City/State: IOWA CITY, IA Expiration 01/06/2018 CDL Cert None 522462723 Date: Status: Endorsements: 3 CDL Med None Status: Mailing Address: 2540 BARTELT RD APT Restrictions: NONE Restriction None 2C Date of Birth: 1/6/1974 Supplement: N Mailing City/State: IOWA CITY, IA Sex: M o 522462723 ;-., -T1-a- i__, - "U — History Information n-‹ iv Convictions , CD XJ`: rn Citation Date Conviction Date ACD Explanation C6unty .1- JUR 01/17/2012 03/27/2012 .592 Speed Johnson IA 02/24/2012 .05/04/2012 S93 Speed Johnson iIA 11/29/2012 03/28/2013 .S92 Speed Johnson: IA Name: Khames, Mohamed DL/ID: 542AG9038 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: hl fAt.' 4�IC(•. 44 8/28/2014 ( z ? i;1) q IO�r®R %e- Office of Driver Services v...:„,„� Iowa Department of Transportation Name: Khames, Mohamed DL/ID: 542AG9038