HomeMy WebLinkAbout15-106� r t
WE,
CITY OF IOWA CITY
410 East Washington Strcct
,,J~_City, Iowa 52240-1826
`-(319) 356-5040.]
(319) 356-5497 FAX
1. Name
Authorization Number_ l 5 —1
(Office use .only)
�OWat/1 �ax( J
APPLICATION FOR TAXIfMOTORIZED PEDICAS VEHICLE DRNER
(Ponce Department review must be made
between 8 a.m. to 3 p.m., Monday–Friday.)
Last
2. Mailing Address _ 2 t & D
3. Telephone: Home -2-0-13-L5591 ,,,_,___ Other.���--��------ —
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? NO
Type of offense
When
e. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs In the last five
years?.4[_O
Type of Offense
7. Have you been convicted of any traffic offenses in the last five years? Ny
Tyne of offense
Where
When
When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Ik
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)
03!2014
I hereby�e r_tif� that I have issued to me by the Iowa Department of Transportation a vaiio Chauffeurs license number
6 YF1(:6
64 I understand that if I falsely answer any questions in this application, that this
application may be denied. I understand that'rf 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 appiication, 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)
Signature of Applicant `—~' ;, V Date ALI-7L2"(�1
YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY
CLERICS OFFICE. Authorized taxi driver names are placed on the city website at lcgov.org.
STATE OF IOWA }
COUNTYOFJOHNSON J
�Subscribed and sworn to before me by VVIZIA „ ,1 `� 2-_R �G jAsl.et . On this _14 tAA __ day of
J 1 x.\61J._wfLL-Y --N dj rJta.AAh.
I have reviewed this application, DCI report, and the State cartified 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).
YZ -.,.e
Sig ure of PQ hief 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 Icgov.org.
Signature of City Clerk or designee
F-1?= iso
Date
Taxi cab businesses are required to provide Driver Identification cards, Cards must be 8 %" (width) and 51/211
(height) and prominently displayed to all passengers.
Office Use Only
Approved appllcation
DCI report
State certified driving record
Website update
dawUW%kKt*VQWPzma= 0312014
iAu;, a8. 2014 12.49PM (Div of Criminal Investigal on
rtiruil
STATX i`J,r YOWA
..�� 1mu1 'r0riminol History Record Check Request Forml
TO: Iawa DiVfslon of Criminal Investigaf!on
Support Operations Bureau, a Floor
215 & 7a' Street
Dae Moines, Iowa 50319
(6M 7254066
(515) 725-6080 Pax
Pk,
NNo" 7633 pP. 2/4
DCI AcwuntNumbex: 7 UQ -.^F— -
VAPPrcabW
Fram: City oflowaCity
City Clerk's Oft e
410 E. W eahfn-yton street
Iowa City, M :42M
Phone: 319-356-5041
Fax: 919 356-5497 — —^
LA5f. 19AIf10 (i51ah0Elafj`J rgae r�amo p„anawoay) IYltddls INable esanmkadcdj
00 l 11 �6 L7Male Female 4' a Cf" S 52 9,2
Waiverb(formalkyl, Without a signed wolwar n"otn the saUJect of fha request, o exrrnplefe crlminai hiatorg recot d may not
barelsasohte, Pot Code ofIowa,Chapter 6912.ildtcgs crlmlnalbtsboryrecolydInforMOlon,asallowed 6Ilaw,always
obtain a walver e1jCnitura from the eublect of the request.
IV111WA4160sd; f batubja(v9 Pu,httelan tar du hove rtquesdng ofnotai m candoct an Jaxa 9dmloal ld#vrytwofd 9hocK wtrL the DIVTsion af4Ynm"
hMIIPd9n0DC0. Ally edmlodMtwtyde(ow)wMk%blo 6tlemafaidooiby697l Mgbo«iwxdarelloatrdbylatr,
waiver
xw},)V�Xi AaV41JA {{. l//!VL[Y. J-4��LL1C1 /I�N'tlyy�(na
As of a scarmh of die provided name and date of b'ia raveem:
c.;
No Iowa Criininal History Record found with DCT ,
® Towa Criminal HistoxyReeord attached, DCI
DCI initials -4
pera7 (08/25/101
Received Time Aug. 13. 2014 1:00PM No -6927
k rka'
00
wumiawadotgov
SI ARTEH I SIMPLER I CUSTOMER PRIVEN
(Waco of Driver Scvv[ces
PO Box =520.6. Ds Friaries, 1,4 5030n•92974
Phone: E'5-244-9124 18)30-1i' 2-5121 1 Far: 515-23u-1637
wom.rokador..gov
Certified Abstract of Driving Record
Inquiry Date:
8/13/2(114
DL/ID B:
569AG6549 CIA)
Name:
Osman, Mohamed
Claw:
D
CDL Med
Ibrahim
status:
Addresmr
2425 BARTELT RD AFI
Audit A:
5696549
2C
Issue Date:
12/21/2011
City/State:
IOWA CITY, IA
Expiration
98/21/2016
522462709
Date:
Enderaements. 3
Melling Address:
2425 BARTELT RD AFI
RestrtclJonsr
NONE
2C
Pete of sirtM:
8/21/1966
Mailing City/Statel IOWA crry, IA
sex:
M
522462709
History Information
Customer 0: 5909707
ID Status: None
DL Statue:
VAL
CDL Status:
None
CDL Cert
None
Status:
CDL Med
None
status:
Restriction
None
Supplement:
Accidents - Accident Involvement Indicated does NOT mean the Individual was at fault or given a.citation.
Accident Clat+ Came Number ,�_..�...�._._...,_ ._. 3UR
05'/12/JC 14 798599 V,
Name: Osman, Mohamed Ibrahim DL/ID: 569AG6549
Pursuant to Iowa Code §321.10, 1, Kim Sneok, Director of ONIw of Driver Services, Iowa Department of Transportation, do hereby
certify that I am the custodian of the records held by the Off[= 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 seat of the Department to be set upon this document, at Ankeny, Iowa this
date:
Name: Osman, Mohamed Ibrahim DL/ID: 569AG6549
8/13/2014
c
Office of Driver services
Iowa Department of?rensportetion