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HomeMy WebLinkAbout18-091IDENTIFICATION NO. —nqj % 1 (Office Use nly) APPLICATION FOR TAXICA9/ �FWQ PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday) CITY OF IOWA CITY p6�,�lc?. . 410 East Washington Street Failure to complete the "require 6-AIno alionP�,I�J§ hin denial of the apoketion Iowa City, Iowa 52240-1826 CITY CLERK 1A CITY, 1C."I.; (3 19) 356-5040 ,i�+'::, ..: (319) 356-5497 FAX First Middle Last P 1. Name (REQUIRED) A hs 6, m c kam e- j 2. Address (REQUIRED) 114S– t,4he,- 4a-0- 422-P2 - t,'.. 'I- T -A SZ24 s. 3. Contact Information (REQUIRED) Email: Cell Phone: (All written communication sent via email) 4a. Drivers License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) G 5. Prior experience in transportation of passengers wap A �5 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? xJ� Type of offense Where When 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? Type of offense Where When What happened to the charge? (Circle one Convict Dismiss Deferred Suspended Plead Guilty Other 8. Has your driver's license or chauffeu s (cense been suspended or revoked in the last five years? �yL 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) (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 04/2018 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 DEPARTMENT OF CRIMINAL INVESTIGATION (DCI}RCTfpRiFf1+IQ STATE CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLI I LICE CHIEF REVIEW You must apply for an individual Department of Criminal Inv 20�9tAUG go$ forfn available upon request). CITY CLERK iO4' n CITY,10%VA I herebbv cEeify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number issued on /16 expiring on e 14+ / 2d I understand that if I falsely answer any questions 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 a Notary Public) Signature of Applicant a Date �5 s5 1 11 Or STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by 2kbd CX on this 1-11-q day of WENDY S. MAYER Ps No ry Pubiic in d for the State Iowa My q� ����e�� e�eef:efr��f.��fn�xrrt+++ •eem�R� 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 date of is Sig of Police Chief or designee Z _L"I- zo,Z 0 8-Z4-/9 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. of City Clerl�-or designee Office Use Only Approved application DCI report State certified driving record Website update ? - �)_Ci _ / ?I Date aeewrMIDRr,BkDcEr aaLsmlea,,a„e,e.00c 04/2018 rinu . I). Zvi0 11:34Hni ulv or i,riminal Investigation No. 9506 P. 2/5 F•..•—••. Clerk „b ..... 11 08/00/201a 18:40 NOBS p,002/002 FILED STATE OF 10$b1WUG 29 PM 2:08 Criminal History Record:lQ'0VckERK r Request Fora► rIrY Ir' To; row& Division of Criminal Investigation Support Operations Bureau, l" Floor 215 E. 71" Street Des Moines, Iowa 50319 (515) 925-6066 (515) 725.6090 Fax anlowa on: M(9kC;kmaA DO Account Number: (ifapplmablc) '� From: C. itv oflowa Cily City Clerk's Office �— 410 E. Washington Street Iowa City, IA 52240 —` Phone: 319-356-5041 Fax: 319-356-5497 ©m,.). ❑Female ('� LA bokYtm- kC- <zs I -66- 5oo'4- Waiver lftjornwiten: Without a signed waiver from be subject of ti be releasable,e request, a complete criminal history record may not per Code of Iowa, Chapter of For complete criminal history record information, as allowed by law, always obtain a waiver signature from the sublect of the reouest, Waiver%felease:ihembygwcpermissim for she above req easing oladal to condun an Iowa aiminalh history mord check with she Division oferiminal Inveaigalon (DCI). Mry amrinal history data eonemring me teat is mainulncd by the DCI may be released u allowed by law. Waiver Sign nfure: Iowa Criminal Histor Record Check Results ([kl ore poly) As of a search of the provided name and date of birth revealed: *41YO Iowa Criminal History Record found with DCI ❑ Iowa Criminal History Record attached, DCT # DCI initials DCI -77 (08/25/10) — C210WADOT SMARTER I SIMPLER 1 CUSTOMER DRIVEN WWW.IOWB(jO1� n DriM a b airviaK PO Box 9:2D1 i Des Mores, IA 5DM&92(M Phone: Sts2ts-91��q�p� 2: 08 History Information CLEAR DRIVING RECORD Name: Abdalla, Mohamed DL/ID: 874AL5703 (IA) Pursuant to Iowa Code §321.10, I, Darcy Doty, 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: Abdalla, Mohamed DL/ID: 874AL5703 (IA) 8/15/2018 A212 DL sem Driver & Identification Services Iowa Department of Transportation CITY CLERK Certified Abstract of Driving Record 0WA CITY, !MMA Inquiry Date: 8/15/2018 DL/ID #: 874AL5703 (IA) CDL Permit Class: None Customer #: 6311770 Class: D CDL Permit Issue None Date: Name: Abdalla, Mohamed Audit #: 1330450 CDL Permit None Expiration Date: Address: 1545 ABER AVE APT 12 Issue Date: 09/28/2016 CDL Permit None Endorsements: Expiration Date: 02/24/2020 CDL Permit None Restrictions: City/State: IOWA CITY, IA 522464708 Endorsements: Chauffeur ID Status: None Mailing 1545 ABER AVE APT 12 Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing IOWA CITY, IA 522464708 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 2/24/1976 CDL Cert Status: None Sex: M CDL Med Status: None History Information CLEAR DRIVING RECORD Name: Abdalla, Mohamed DL/ID: 874AL5703 (IA) Pursuant to Iowa Code §321.10, I, Darcy Doty, 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: Abdalla, Mohamed DL/ID: 874AL5703 (IA) 8/15/2018 A212 DL sem Driver & Identification Services Iowa Department of Transportation