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Home My WebLink About14-044 lAuthorization Number 1 (Office Use Only) FIE Exce;Ara, APPLICATION FOR TAXI 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 Last 1. Name \'‘ n\�:e , �c��_N 2. Mailing Address ),L►-`)- �co�� e �Y E �1� out a (' s �� 3. Telephone: Home 1 G c13 6 Other: 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 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 N ) ,a 7. Have you been convicted of any traffic offenses in the last five years? 'I C Type of offense Where When 8. Has your driver's license or chau eur'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/laxidrivbadg 03/2013 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number (-) `v . 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 _�`— _�- Date )rZ g J 61 Lt' STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by e yln , r Al i . On this c Z ±LA. day of {\_,k c.-J+ .. aol y ` WPl aur Notary Public in d for the State of l a t ACNDY 8.MAYER 4 Commission Number 729428 ••_' ' My C.m ission Expires ****** ,......., * -*. l,c ,V********* ****************************************************,t********,t***************************************** 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). • 02—aS W Signat e of Poliy 'ref 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. Signatu z of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 '/2" (width) and 5 1/2" (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update clerk/taxidrivbadgeapp2010.doe 03/2013 Feb. 20. 2014 9: 55AM Div of Criminal InvestigationMo 3427 � L P. 15/15 1 4 v. iv. L V 1 7 L.JV I III V I LrV 1 4 1 A V 1 L VI Lurid V 1 Ly { t STATE ®F IOWA cm„ Clfn mmol)/ostomy Recorrdl Check z r ` `'5. �^"a' IN44 �I .) (4 .• L ..,%.:;.2.7:. Y dit1 k. r DaAccauntNumber: (1004, (ftsppiloeblo) Tot Iowa Division of Criminal Investigation From: City of Iowa City Support Operations Bureau,l't Floor City Clerk's Office 2151y.9th Street 410 B,Washlnton Street hes lZoines,Iowa 50319 (616)125-6066 Iowa City, IA 62240 (913)123-6080 Fax Phone: 3193565041 Far: 319356-5497 I em re,uostln: an Iowa Criminal IlistoryRecord Check on: Last Nakao mandato , FineName(mandato,y) Middle Name recommend • Date of Birth mendeloGender mandatory) rf.U,Situvul l n11be rcoommat. .' i i -6. 3 (- 1123- Male 0Female 1 ?j lj - 2. ,- rnliVer li4fOrMae ft:Without a signed waiver from the subJect of the repeat,a complete criminal history record may not • be releasable,par Coda of Town,Chapter 69/2.Fprpomuleto criminal history record information,as allowed by law,always obtain a waiver sl• afuro from the sub act of the re.nest. Waiver Release:ihercbyglvopormhdon for the ebove requesting oaioi,lfa conduct an Town criminal history record chcckwith the Division of Criminal Investigation(Del). Any nr/mInal history dela concerning ma thaQa maintained by am DCT may Ise released aa allowed bylaw. Waiver Signature: a 1 .�..L.. t . I • - Iowa Criminal Wigton Record Check Result6 amp?,ons As of 2b-D1`4 , asearch ofthe provided name and date ofbirthxevealed: :.e'ec m nrCL) No Iowa Criminal History Record found with DCI n toco ti r ® Iowa Criminal History Record attached,DCX# --" N DCI initials Received Time_Feb. 18.,:2014— 2:35PM—No. 3206 pig" -..1 cc, ---, ,::::, ITI N. : 4 4,,,. . SMARTER I SIMPLER I CUSTOMER DRIVEN www iowadot.gov Office of Driver Services PO Box 92441 Des Moines,EA 50306-9204 Phone:515-244-91241800-532-1121IFax:515-239-1837 www.iowadotgov Certified Abstract of Driving Record Inquiry Date: 2/28/2014 DL/ID#: 266AD7808(IA) Customer#: 5429309 Name: All,Samir Isameldein Class: D ID Status: None Address: 2427 BARTELT RD APT 28 Audit#: 7504999 DL Status: VAL Issue Date: 11/06/2013 CDL Status: None City/State: IOWA CITY,IA 522462710 Expiration Date: 11/03/2018 CDL Cert Status: None Endorsements: 3 CDL Med Status: None Mailing Address: 2427 BARTELT RD APT 2B Restrictions: NONE Restriction None Date of Birth: 11/3/1985 Supplement: Mailing City/State: IOWA CITY, IA 522462710 Sex: M History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 08/28/2009 1.10/16/2009 •592 Speed Johnson 'IA 09/09/2009 :11/25/2009 X592Speed _ _ __ _ :Johnson SIA 01/28/2012 •04/04/2012 'Improper Parking on Highway Johnson IA Accidents-Accident involvement Indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 07/27/2012 ;696745 SIA Name:All,Samir Isameldein DL/ID:266AD7808 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: 3 1u11 1: ( X) / 2/28/2014 c` ^'1' s rhti AA owaaDepartment ofof Driver lTrransportation Name:All,Samir Isameldein DL/ID: 266AD7808