HomeMy WebLinkAbout15-028410 East Washington Street
Authorization
/j�t!Y°o(CtY�
Number
(Office Use Only)
APPLICATION FOR TAXI I MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.)
—...... .. . - _ w . tbim........ i will r'eSrrlt nrr denial of the gTrp ?OL g
Iowa City, lova 52240-1826 dRa �rRt'e'd a 'wE dreww�`w't wt ar w._� ._ I�aad r" °wq tart......b�'_�..........................�..._..........._.�_____
(319) 3S6-SO40
(319) 356-5497 FAX
Firs Middle /y Last
1. Name (REQUIRED)
2. Mailing Address (REQUIRED)
r
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? No
When
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? L1 �
Where
am
7. Have you been convicted of any traffic offenses in the last five years' N 0
Type of offense
Where
When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /V()
Type of offense
Where
M
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide'the r;ine(s)
Min -1
11 1
ea
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIEI ,
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
hereby certify that U have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
'7'm ASI aC� ("� . 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)
YOU ARE NOT VAI -ID TO DRIVE ATAXI IN IOWA CITY UNTIL. AUT HORI74TION IS REC EIVEG 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 before me by �� ��a� & m � a V 53M_,. ,,, On this day of
�......
Notabi-Public in and for thb State of Iowa ..P PI t fl'l
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).
Sig�1e f flce Chief or designee
l
Die
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.
Peel� Signa of City Clerk or desig
°5
® Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8'h" (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 _ r''
r
ClerkrrAXIDRNBADGEAPPL92014amended.DOC 09/2014
Feb. 2. 2015 9:16AM Div of Criminal Investigation
Jan. 30, 2015 1:07PM City Clerk ""' City of Iowa City
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Daws Momeg, low -b "54319
(5.15) 7264666
(5.t5) 725.6080 FAX
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Iowa City, .yA 5224
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Certified A4alttwact of Driving IIRCCOrd
Inquiry Dater
1/23/2015
Ili./Ila #r
750AI9917 (IA)
Customer #r
6161790
Name:
Mohamed, Mohamed
Clasen
D
Io Status:
None
Hired
Addresm
319 FINKBINE LN APT
S Audit #u
8789054
DL Status:
VAL
Issue Dater
01./23/201,5
COL Statum
None
City/Stater
IOWA CITY, IA
Expiration
11/10/2018
COL Cert
None
522461705
oaten
statmn
Endomementm 3
Cot Med
None
Status:
Mailing Add
3:1.8 FINKBINE LN APT
5 Iltestrictionm
NONE
Restriction
None
Elate of Blrthu
11/10/1986
Supplement:
Mailing City/ ter IOWA CITY, IA
Sam
M
522461705
History Information
CLEAR DRIVING RIECORD
Name: Mohamed, Mohamed Hired Llll./ID: 750AI9917
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°M10
7./2"I,f2E15
I�
ry
„nr
i u� r
Office of Driver Services
Iowa Department of Transportation
Name, Mohamed, Mohamed Hired DL./I®: 750AI9917