HomeMy WebLinkAbout14-210i
e r
,�► :rlll A"
CITY OF IOWA CITY
410 East Washington Street
]Diva C %va 52240-1826
(319) 56-5040
(319) 3 97 FAX
Authorization Number
�— (Office Use Only)
APPLICATION FOR TAXI / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.)
f°ae/ure tax corual,s(a a .:( /g..u6r cf bra fP'" irsfor�raaf/c�av nr6Rf �a.sarll
First
1. Name(121:A:7t.11RED)
2. Mailing Address (IfEQtill ED) 1.0
3. Contact Information (RF=QUIRED) Email
in derdad of fd�c r��t 9�tW®��a¢uxu
o ... �r-
�? r� na?rr Cell Phone ''a��rsr�ra r
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?( s _
Type of offense
Where
NIM
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? 2 L—,
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)
09/2014
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or "' �
inlf'§b
last fi
years?
Type of Offense Where
.n
r,„.�
..,.o
11C
IVB ".', ,
7,. Have you been convicted of any traffic offenses in the last five years? L, C`)
Type of offense Where
When
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? 2 L—,
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)
09/2014
I! hereby certi that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
9, A `e -&P �w � . 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
Signature Ptl�li ant,
° 1 ,.
9 pP Date
i
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 fcgov.org.
STATE OF IOWA )
COUNTY OF JOHNSON ) C
t.
Subscribed and sworn to before me by m•uu ti� &'��v Q `m t• On this day of
te
Notary pub.
in and for he State' f Iowa _..,_.,.. .
nd
r h i A,) f..(
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).
Signature i ief 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 fcgov.org.
Signa re of City Clerk or designee
Taxi cab businesses are required to provide Driver identification cards. Cards must be 81121(width) and 6 W
(height) and prominently displayed to all passengers.
y.'11
il1•v.'�,i
Approved ap,{p rtcatlo<
, brI r..DCI report ,
P
b
State certified driven recoil"
Website up' i00
a;
t
„;,
Office Use Only
ClerkrrA%IDRNBADGEAPPL92014amended.DOC 09/2014
Mohammedall,
Caaa'tIffaad Abstract of Drtvftlllg Rarcurd
City/stift. IOWA CrM LA 5224641038 =p1roattnev"alli»,
Endormsemen
`g 2610 , APT a Restrictions;
Date-"afling 0tv/Statm IOWA CITY, IA 522464038 S=N
SZ&AK0862(IA)
0
ED Status:
None
842,2075
lid. Status.
VAL
09/05/2014
COL Stabun
None
11/25/2016
CDL Cart Stating
None
CDL
NONE
Restriction
None
L
Hi®tnyv information
,r r , rw s e ♦ e I I u ` e` �+ nd. r, �r
„
5 ^I JEne Usector } f 1
Iowa r W 1 R, it fi: } A
so
In witness whereof, d have caused my signature and the seal of the Department to be set upon this document, at Ankeny. Iowa this date:
Name: Mohammedan, Way Abuelgasim yagoub DLj1D- 828AKo862
9/5/2014
Office Of Driver SerAces
Iowa Depar"ent Of TranSPOrtallon
;Sep. 13. 2014 12:54PM(Div a'P Criminal 1 Investigation NNo,01B4 p.P• 1
STATE OF IOWA
CAm"na R History.Record Chet
e
DCT Account Number: ,.._s ...-.
To® Ioeva Division of Crlminai Investigation F'Va m .,City oflayya Citi ...........................
Support Operations Bureau, P Floor City Ciarlt%s office
215 L. las Street 410 r:. WAIN icwtona Street
Des Moines, rown 50319
(615) -6066®�wa CBtyaA 5240
(515) 725.6060 Fax
Phone; 31.0;3,55-5041
...................................................................................................................................................................
Fax: 131. )-356+56?97
X aamr mquestinS ma rowvn. Ofinhhal 16xr %record Check can.
.�.ed3�'i�°�aYke (rrsandaYaeyy ......................... .virst..Name(oundAwry) i nddie. 9;A8¢e (reaonvnuended}
Date ofBirth (mendaoay) Geader (naandawy) som.1al Secret!..R;f:Nanmber (¢¢so,oaaeaod¢dy
: y `765..: I �._
Wddaref Zaafbrhattafd®8tt Without a signed wabvm .1w•ow tlae,subject of thea ¢quest, a complete ea°faniimai history a ooaa ffi may hart
ba zoleasalriw, per kande of Iowa, Chapter 6.92.3„:icor .c.o .1KLq criminal hWoiry record roforemakion, as allowed by taw„ aiwaits
in w iverai naltaa°orcmtllesarlr'cetoftYmoeeauestw .
Waiv'er.Relatre!'.t.$carbyAlvrepe®umVnaivofor the( rvbovaucq,u'crr.fnroffidalNcan�drekonIOWA mmirr l hqsloay[V4rdchcekVd1hthrDivisio-nofCuWiiRM
Inveea%edon(DC).�xiy¢rkneireflVsteaydad�awnosariosnrnkltea ts6f .d by bbDClmay bereVeaedmalowedlbykw.
.
Waiver Itma¢'sea°ac d
.......--.._. .........
.Iowa._�"°1�2�na:ilnal fistfiry Record heck :I es ulty (DC1useenzy}
As of .. a search of the,provided name and data of birth revealed:
later IowaCrisvinall:��ator.yPecord.forendwithl7CI
Iowa Criminal History Record attached,, .DC:1 N
I
eceived Time -Se . 8.-2014 4r45PK-N o. 90
Lt'i-7i (aiaiLcai00