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Home My WebLink About14-180 Authorization Number r `I I L1 1 (Office Use Only) • �► "` wllr®pc� APPLICATION FOR TAXI/MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made 410 East Washington Street between 8 a.m.to 3 p.m., Monday—Friday.) Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX First - Middle ��f , Last I SS � t Name C I Y J Ali C.L�c �'I/ c�) (.7 2. Mailing Address Zl// ��(rf e/L/ , t /A , Za(.4./ Cir= ., 1A 5 3. Telephone: Home Other: ,5?1 9, 3 g3 • 95. ,5 4. Prior experience in transportation of passengers: 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When V 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 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? 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). (OVER FOR REQUIRED SIGNATURE AND NOTARY) clerk/taxidrivbadg 03/2014 I heby certify that have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number X74*V to 6 . 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) Signature of Applicant i L t- Date O� ' 2 5 -14 Wall` f:s 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 ) h Subscribed and sworn to before me by ss\r '\. \q r o v . On this day of ublic in and for the State of Iowa k11 I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter- mined that there i no information which would indicate that the issuance would be detrimental to the safety, health or welfare o -siden . • - City of Iowa City(Title 5,Chapter 2, City Code). 10° Sign. ur- .f 1: ,-'a 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. k . �,s4/ g - —/ Signat of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2"(width)and 51/a" (height)and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update cleddtaxidrivbadgeapp2014.doc 03/2014 1Abg. 22. 2014 .1�2,•T13PM (Dii Lv of C�iminalrInvestu . �gation NNo�8159 v IU PP.• � 1/1 :,(,,,�,.;;, STATE OF IOWA• `I' °, . (.4t.:stify,y , Crnrmmur®al History Records Check . ':" "�' . . t ,� f.:s, jr • 'Request Form l •, fi� i:N dam/ :;*1-t • • DCI Account Number: Vc ` • (itepplieehle) To; Iowa Division of Criminal Investigation rpm City of Iowa City Support Operations Bureau,1"Floor . City Clerk's Office 215 E.1th Sweet - 410 F.Washington Street Des Nobles,Iowa 50319 (515)125.6066 Iowa City, IA 52240 • (515)123.6080 Fax Phone; 319356-5041 • he : 319.356-5491 • •I am requesting an Iowa.Criminal Tllstory Rbcord Cheek on, Last Name(mandatory) yyrst Narita(mandatory) Middle Nome(recommenicd) Date of Birth(mandatory) Gender(mendatry) Social Security Number(recommended) Of 0/ " // 7� Male Female Jo ,t-e2.7—l56i V .. • Wft&Ver iriformaiI'on:Without a signed waiver from the subject of the request,a complete criminal history record may not be releasable,per Code of Iowa, Chapter 6912.For complete criminal history record Information,as allowed by law,always . obtain a waiver signaturo from the sub feet of the request. Waiver Release:I hereby give permission for pia aboVo requesting official le conduct en Iowa criminal filmy record check with the Division of Criminal Investigation(DC1). Any criminal history data concerning mo that is maintained the DCI my be released as allowed bylaw. Waiver Signature: • Iowa Criminal History Record Check Results (DCI use only) • As of g'22- i 1 ,a search of the provided name and dafe of birth revealed: Jr ,-5 CFR No Iowa Criminal History Record found with DCI • 0 Iowa Criminal History Record attached,DCI# • ' • . t') DClinitials • M Received Titael;Ag; 19;,x2014 12:37PM No, 7723 • � q .4 n WWW towe date gov SMARTER I SIMPLER I CUSTQMER DRIVEN .w. .s Office Of Driver Services PO Box 9204 I Des Morns,IA 50306-9204 Phone:515-244-91241800-532-1121 [Fax:515-239-1837 wv.wiow.adot.gov Certified Abstract of Driving Record Inquiry Date: 8/20/2014 DL/ID#: 836AK8126 (IA) Customer#: 6089470 Name: Haroune,Yasslr Atidjanl Class: D ID Status: None Address: 2411 BARTELT RD APT Audit#: 8368126 DL Status: VAL 1A Issue Date: 08/19/2014 CDL Status: None City/State: IOWA CIN, IA Expiration 01/01/2019 CDL Cert None 522462706 Date: Status: Endorsements: 3 CDL Med None Status: Mailing Address: 2431 BARTELT RD APT Restrictions: NONE Restriction None 1A Date of Birth: 1/1/1971 Supplement: Mailing City/State: IOWA CIN, IA Sex: M 522462706 History Information CLEAR DRIVING RECORD Name: Haroune,Yasslr Atidjanl DL/ID: 836AK8126 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: >�eQ4. .•. p`� I 8/20/2014 ((� ' IOWA •.$ r rI he/.. Sz`r Iowa Department of Driver ServiTransportationces Name: Haroune,Yasslr Atidjani DL/ID: 836AK8126