HomeMy WebLinkAbout15-066it �III�
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa S2240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. i
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
Failure to complete the "required" information will result in denial of the application
First
-A ✓vx
2. Address (REQUIRED) ) Q Ci 1 () r� 1� ( e Com, i„ 2 ZIt
3. Contact Information (REQUIRED) Email:gr�ty �_1Cc 1 x v 45 yG� -Coy , Cell Phone:l31
(All written communication sent via email) / t
4a. Chauffeur's License expiration date (REQUIRED) _6 t A .J � 2- ; s c) 9 / % s
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers: `/ e S
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? N ID
Type of offense
Where
When
What happened to the charge? (Circle one) MAR 1 9 2015
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? &IJ
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 4✓0
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 then�me(s)
o
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).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I he certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
i A D -2--?issued on •-2'z -r'3 expiring on `. Is 2) 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 Date a'-3 -11:9 - V5
STATE OF IO1NA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by on this 1� �� day of
Notary Public in nd for the State Of lowa�
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).
GiU 1-? 2015
Signete of Phief or designee Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA C)TYFOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
THE EFFECTIVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION IF LESS THAN A YEAR.
Sigl`Tat6kof City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
3� \-, \ 1!y-
Date
ClerWT IDRIVBADGEFPPL92014emended.DOC 02/2015
C410WADOT,ShAAF,iER {SIMPLER I CUSTOMER DRIVENNtl°"'�ti.1�iV1tt dot.gov
Office Of Drivel 5e7177s
F'O BOY 9204 1 Des i'Aoine:s, +4 50Ki 5-92C4
Vhc4 -515-2&1-912A1.1300='3 1121 I Fay :i75-1v:� Y:127
Inquiry Date:
3/19/2015
Name:
Sharif, Ayman
Expiration
Mahmoud Mohamed
Address;
1901 GRYN DR
City/State: IOWA CITY, IA
522464408
Mailing Address: PO BOX 1555
Mailing City/State: IOWA CITY, IA
522441555
Convictions
Certified Abstract of Driving Record
DL/ID #: 679AJO237 (IA)
Class: 6
Audit #:
7062538
Issue Date:
06/22/2013
Expiration
09/18/2018
Date:
Johnson YIA
Endorsements: PS
Restrictions: NONE
Date of Birth: 9/18/1967
Sex: M
History Information
Customer #: 6073198
ID Status: None
DL Status:
VAL
CDL Status:
VAL
CDL Cert
Excepted Intrastate
Status:
Johnson YIA
CDL Med
None
Status:
Johnson IA
Restriction
None
Supplement:
Ciba&ion 0 _e
Convictlon Dat'
: CD Erxplao'aion
Cotankv :lt3t=:.
09/01/2013
'09/27/2013
S92 Speed -- -` ....... .
Johnson YIA
03/08/2014
.04/08/2014
.592 :Speed (10 mph & under in 35-55 mph zone)
Johnson IA
Name: Sharif, Ayman Mahmoud Mohamed DL/ID: 579A30237
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:
..........o'S
3/19/2015
IOWA
try
D. 0. T.i_497
06cl
f '••••" e�='
Office of Driver Services
Iowa Department of Transportation
Name: Sharif, Ayman Mahmoud Mohamed DL/ID: 679A30237
Mar. 9. 2015 1:;3PN' Civ o` C r i m I r a I Invesfigaflon
Mar Uo' [uio V15:1 IF'M Uty of Iowa Uty d'1 y -339-b J93 Page 2
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QrindnaR Msifuiry Record t fl l�
� IdOyla 1qc;r l 1!l i 1 I P II I
Tw Iowa lllvislon of Criminal 7nves0gadon
t)uppoat ®perstlons Bureau, I" Floor
215 E. 7"' Street
Des lblolnes, Iowa 50319
(515) 725.6066
(515)725.6080 Fax
Va.2019 P, 1/'
a.OU.
DCI Accounthunnber. 't-op-�'--�7
(if app11rn510
From: _City of Iowa city
City Clerk's Office
410E. Washington Street
Iowa City,rA 52240
Phone: 319-356-5041
Fau 319-356-5497
I am Ye uestin en Iowa Ctiln nal H oto Record Check on:
Last blame (niandarory) I First Some (mandae rvl 1�IldriOa hfaamo t.. . n
S;,kGrl'�— I Xgogo,, I Mahm6l-k4
[tate of Birth (mandato y) ] Gender (mandatory) Social Security Humber (re ooimuided)
al ' R l "I Fal Mmale ❑Female L,'
Waiverinfarrualion: WKhnutasigned waiverfrom the subject a[ the, request, acomplete crIWrialkWaryremrdmay nol
ba releasable, per Code of Iowa, Chapter 692.2. For complete crlmival history record information, as allowed bylaw, always
I{ ITIVer'RetetrSe: I hetehy gtvc pcnuission fbr the above rcquufingo to ronoctan lows criminal hislorymcardchcck withlhe Div,siunor Criminal
Ieyesfigalion(I)CQ. Myeriminal bisroq dela eonceming nm dtatbmeb ed byl lidra!a.ma allewedbylaw.
Waiver Sigxrnlure
Iowa Criminal isto1y Record Check Restl9ts �Dc, usaanly)
As of y a search of the provided name and date of birth revealed:
nNo Iowa Criminal History Record found with I)CI
13 I016va Criminal History Record attached, DCI #
DCI initials_
DCT -77 (08/25/10)
Received Time Mar. 6 2015 2:33PM No, 2387