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Home My WebLink About15-094CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO. / C� — O I L/ (Office Use Only) APPLICATION FOR TAXICAB I 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 Middle Last 1. Name (REQUIRED) 2. Address (REQUIRED) ��y��"�.%✓e �i4�c'r/fit i7 5�2y� 3. Contact Information (REQUIRED) Email: Cell Phone: 19" �'�✓ �' (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) d'/ 2 3 /6 b. Taxicab Business Name (REQUIRED) _ � //O+ j Ls1 c5 5. Prior experience in transportation of passengers: etc. r h« e— Se /7 ,� Ser e S 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? nlr-D 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? ls.14 ? Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilt Oth89 8. Has our driver's license or chauffeur's license been suspended or revoked in the last fiv ? o �d y p Type of offense Where Cerfo - -t 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, pleasrovideWe nam s) r 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 hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number e''73 1.1�V4.6 2 3 issued on 42 /iy expiring on aYl? 5 /;?� /6 . 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 0W22Plklld_ STATE OF IOWA ) COUNTYOFJOHNSON ) Subscribed and sworn to before me by M �w a t c, n on this (:�IQ k, day of 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 Chauffeur's license Signature o Polic Chief or designee . 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. � 2!L. �o� Signature of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update �- 7 ice Dat8 v- f�^C N Clerk AXIDRIVBADGEAPPL52014amended.DOC 03/2015 04,Ap1.23. 2015,9:41AMcenDlvof-Crimina1 Invesfigafloo (Fnx)31933e0o,5622 P. 1/12 /002 STATE OF IOWA Criminal History Record Check Request Form To: taws Division of Criminal Investigation Support Operations Bureau, I" Floor 215 E. 7ie Street Det Moines, lows 50319 (515)7x5.6066 (513)'725-6089 Fax n1'114 O 0 08/43/ 19r/v /i!o 1-140VO 0 DCI A000unt Number; _9967-F (if applicable) From; Yellow Cab of Iowa Cf P.O. Box 428 Iowa City, IA. 52244 Phone: (319) 338.9777 Fax: (319) 339-7302 amide ❑Female G.fr7AA'e 3/,7- gn q- 0 7, 3 waWe? InjormafloA; Without a signed walvor from the subject of the request, a complete criminal history reoord gtsy not be relessablo, per Codo of Iowa, Chapter 692.2, For ggiil2lato criminal history -record Information, ase allowed by law, always obtain a waiver sianatura from the suhleet of the rnen.oee Waiver Release; I hereby sive permbelon for tho above requecling oaeclal to condua an IOWA criminal history reoordcheek whh the Division ofCrhnlnel Investigation (DCI), My eylmlasl history data concerning me Thai Is ms(ntalnod by the DCI may bo rolossed w bllowae by law. Waiver signature! —------- ---^ ...,�..,...e PCI laeonly) As of a search of the provided name and date of birth revealed: , No Iowa Criminal history Record found with ACIr'' `-: ; ;13 � m r ❑ Iowa Criminal History Record attaohed, DCT 4 :t� -U rr7'til 3 y, Jr DCI Initials PAA--, r r•' w DCT -77 (08/25/10) Received Time Apr. 20' r. 2015 4.42PM No. 5893 CIowa Department of Transportation Office of ORAN sew" f7oll Free) aW 532-1121 PQ Ellox 9204, Des Moines, K 503D69204 515-244-9124 AW W'515 230 1537 Certified Abstract of Driving Record Inquiry Date: 4/20/2015 DL/ID #: 623AH4523(IA) Customer #: 5946835 Name: Nugod, Mohamed Class: 8 ID Status: None Medical Examiner National Registry Number Osman Medical Examiner Jurisdiction IA Medical Examiner Phone 319 356-3335 Address: 991 22ND AVE Audit #: 8256687 DL Status: VAL Medical Certificate Expiration Date 04/01/2016 Issue Date: 07/15/2014 COL Status: VAL City/State: CORALVILLE, IA Expiration Date: 08/23/2016 CDL Cert Status: Non -Excepted 522411508 Interstate Endorsements: PS CDL Med Status: Certified Mailing Address: 991 22ND AVE Restrictions: NONE Restriction None Supplement: Date of Birth: 8/23/1940 Mailing CORALVILLE, IA Sex: M City/State: 522411508 CDL Medical Examiner's Certificate Certificate Specifics Explanations Medical Examiner First Name Claudia Medical Examiner Middle Name JUR 01/19/2013 Lynn Medical Examiner Last Name Corwin Medical Examiner License Number 29261 Medical Examiner National Registry Number 8795856463 Medical Examiner Jurisdiction IA Medical Examiner Phone 319 356-3335 Medical Examiner Type Medical Doctor Medical Certificate Restriction 1 Wearing corrective lenses Medical Certificate Issued Date 04/13/2015 Medical Certificate Expiration Date 04/01/2016 Date Added to CDLIS Driving Record 04/18/2015 History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 01/19/2013 01/25/2013 592 5 eed Iowa IA Name: Nugod, Mohamed Osman DL/ID: 623AH4523 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: Vhf Vijay 4/20/2015 `iow� ''` D. 0. T �q.a•.d 3 n�e> Office of Driver Services Iowa Department of Transporation Name: Nugod, Mohamed Osman DL/ID: 623AH4523