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HomeMy WebLinkAbout14-202 Authorization Number I l -alb - 1 (Office Use Only) -_a czO rlll •st aft 141111r CITY OF IOwA CITY APPLICATION FOR TAXI I 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 (319) 356-5497 FAX 1. Name(REQUIRED) First /I n ACS Middlevo /1 14 Last 2 V(aiv 1 2. Mailing Address(REQUIRED) ' •1 2 f 51/\ 5+ / __LO u../ 'c" �� 1 1/1 3. Contact Information (REQUIRED) Email: ,71.A yY►/d r4 3333 � �„��Cell Phone:,5/2— 321- c ,C>c/9 4. Prior experience in transportation of passengers: �/'�,,is © 7 d-V q � r .4/tFcuv�� 7 Tnw1 c', ' l ot-- 4 c U6 L v; 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /v 0 Type of offense Where When 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? /I,; (.' Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? f v O 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) �r7 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 certi that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 7 q . I understand that if I falsely answer any questions in this application, that this plication may e 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) Signature of Applicant Date 0j—63 _ 1 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. ************************************************************************************************************************************************ STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to bef• e me by �(0\A p L..ti A . Sc f,-c . On this �tk day of ) P«� WWENDY S.MAYER - ` _ ,., `^ .mmisslon Number 729428 Notary Public in and fe�the State of Iowa 4 ************************************************************************************************************************************************ 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). q / s/,-, Signature ofi e C 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. -22tie.,14-c_) -e. -1 `c/a,/i < Signature of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 81/2" (width)and 5'/2" (height) and prominently displayed to all passengers. ************************************************************************************************************************************************ Office Use Only Approved application DCI report State certified driving record Website update Clerk/TAXIDRIVBADGEAPPL92014amended.DOC 09/2014 PrP 3/Aueg. 1,8. L2014112 .49PM CDiv of Criminal Investigation NNo; 7633 pP. L. 1/4 I 4 g®o • l STAT• E O I® Jf nit, • flikiipt . 3Criminal history Record Check 7 e .a Request Form �r;'-- ,r' DCI Account Number: L` 0()'2 -- r • (if applicable) To: Iowa Division of Criminal Investigation Nrom: City of Iowa City. Support Operations Bureau, 1feEioor . City Clerk's Office 215D,7th Street 410 t.Washington Street Des Moines,lows 50319 (515)725.6066 Iowa City, IA S2240 (515)725-6080 Fax .,. Phone: 319-356-5041 Fax, 319-356-5497 `1/4.oCY.1 ) . • I am requesting an Iowa Criminal History Record Check on: Last Nstne(nsandalory) _ First Name(inandaroty) f Middle Nature(recommended) Lir _Date of Birth.(mm dotory) Gender(mandatory) Social Security Number(reoornm tided) ob r ( 7- - /6/7-3 7-3 AMale D esnale 67 ' - . lj .4 - Soo z WaiverInformationa;Without a signed waiver from the subject of the request,a complete.criminal history record may not be relensable,per Code of Iowa, Chapter 692.2.Nor complete criminal history record information,as allowed by law,always obtain a waiver signature from the subject of the request. Waiver Release;l hereby give permission for the shove requesting official to conduct all Iowa criminal history rccard chock with the MI/Won of Crlminsl Investigation(DCI), Any criminal history data concealing me Maris maintained by the DCI luny be rcfcased as allowed by law, Waiver Signature: .� � 1 Iowa Criminal History Record Check Results ' (DClvre only) . As of Ck'.1 %`i ' I , a search of the provided name and date of birth revealed; • No Iowa Criminal History Record found with DCI . ` ' 0 Iowa Criminal History Record attached,DCI#_ DCI initials I - - DCI-1/7 (08/2,Vl0) Received Dlime Aug, 1J. 2014 12: 09PM No. 6924 y .n/,iowaCnt gc Office of Driver Servici s PO Box 9204 I Des Moines,IA 56306-9204 Phone:.515-244-9124 1800-532-1 X121 I Fax:515-239-1837 wwtv_iowadot.cev Certified Abstract of Driving Record Inquiry Date: 8/21/2014 DL/ED#: 450AF6378 (IA) Customer#: 5729103 Name: Sharif, Mohamed Ali Class: D ED Status: None Address: 1121 ASH ST Audit#: 6115230 DL Status: VAL Issue Date: 07/11/2012 CDL Status: None City/State: IOWA CITY, IA 52240 Expiration Date: 08/17/2015 CDL Cert Status: None Endorsements; 2 CDL Med Status: None Mailing Address: 1121 ASH ST Restrictions: NONE Restriction None Date of Birth: 8/17/1978 Supplement: Mailing City/State: IOWA CITY,IA 52240 Sex: M History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 11/20/2010 02/15/2011 'M14 Fail to Obey Traffic Sign/Signal Johnson IA '. 05/11/2012 -__,. 08/14/2012 M70 Improper Passing _ ,,.__ _._ .,_ Johnson. ,_ IA, .._,4....,i 12/07/2013 01/22/2014 S92 Speed Johnson IA I Name: Sharif, Mohamed All DL/ED: 450AF6378 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: /_e•***....p„4s 8/21/2014 ,g: IOWA t p. O. T '�' * i. r' `,aialh4ft % Office river Services Iowa rtmrtvicansportatlon Name: Sharif, Mohamed Ali DL/ID:450AF6378