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Home My WebLink About15-110l r t CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. /.5 —//0 (Office Use Only) Kelri co vv rfl- r -i CAU 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 Middle Last 2. Address (REQUIRED) Jai '1cd- At^e _ (ara i ; i�p 'A 3. Contact Information (REQUIRED) Email: yuck_ E i9t Jt<P- ,. / e,,,, Cell Phone: (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) o2114 1 2„9 e) b. Taxicab Business Name (REQUIRED) —in �- 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this Stat6r elseEere? ,L� E C1 Type of offense Where )si � -TT en z r.... C -) —<t F What happened to the charge? (Circle one) Convicted Dismissed Deferred ;ts Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense What happened to the charge? (Circle one) Where When 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? /i / 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 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). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02.+2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify th t I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number �_�47�4'rz issued ona o� 2 — expiring on oz/� 20 . I understand that if I falsely answer any questions in this application, that this application may be denied. Igrey e 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 52 ✓ Date oG% 2,01S7 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by - M )"Ki u., -C-0 h nJ ct I ( c on this j �� day of i --i.... n -"w l'�i 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 Chauff u 's license Signature of Police Chief or des ee Z020 N 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. �2t> 7r. � Sig tune of City Clerk or designee Date N Office Use Only GP `^ ?n L Zen Approved application C"7-< 1. -.- DCI report State certified driving record Website update N C=) co cieddr IDRIVBADGEAPPL92014amended.00c 03/2015 Pr 26, 2015µ4:17PMcarDiv of Criminal Investigation os 22 X06 ry6 No, 8106 DeP.r1/2 OO2 n ,foe+:rru<c,. STATE F IOWA CAminal History Reco.rd Check IOWA _ Request \•, _ u ��rGS.CIAMSMbr 'rat Iowa Division of Criminal hlvegligatlon Support Operations Dorm, V Floor 215 L. 71' Street Des Molnes, Iowa 50319 (515)725-6066 (515)725-6080 Fax 1 � , 1.....A V-6.rt Chcclr n, - DCT Account Niimber: _ (ifnppl'icablc) From: City of Iowa CTEV City Clerlt's office 410 L. Washing(an Street _ lova City, IA 52240 Phone: 319-356-5041 Fax: 319-356.5497 Last Name (mandatory) First Name (n,andalory) 1liiddle Name (rewinmended) Ahdu f,Lo,i, ® Towa Criminal Hisrory Record attached, DCI #}-r*) vto60, tc �.( Plate of Birth (mandamry) Gender (insodatory) Social Security Number (recommended) V i��i�rjl I/� �j ® le ❑Female Jr - � .- 7— Waiver Infortnpfion., without a signed waiver from the sub]ect of Isle request, a complete criminal history record may not be releasable, per Code of lows, Chapter 692.2. For complete criminal history record information, as allowed by labv, always obtain a Ivaiyer signature from the subject of the r¢ nest. ff"ai ver Aclease; I hereby give pemui55i. for the shove requesting official to coodvcl a,r Iowa criminal history record check with the Division of Crindnal InVeStigation (DCO. Any eeilm m.1 pistoiy data concerning me that is mainlaipcd by (h.))CI may 66 ialeased as allowed by law. N�aiverSianulure:---��}�w� b ate^•^_•�— Y ...-_ _ � tiJ Iowa Criminal Histor`r Record Check Results (0cl Ilse anly) As of I ab 11, a search of the provided name and date of birth revealed: No Iowa Criminal Histw3, Record found with DCI ® Towa Criminal Hisrory Record attached, DCI #}-r*) �.( �7 '13 DCIinitials- !v`-_ U DCI -77 (0E/25/I0) w Received Time May, 22, 2015 2'55PM No. 8160 C-410WADOT ..__r w c,w; c f" , 1 �INW.E l 1 ' 111 f(IME$ DRIVEN C:ffice of Drivel Servii'as PC, Ro,, 8204 1 Dei sAnrr,s.% i.A 5`]3^'i '3=04 Phone: =.:15 444 2124 1 21Cv-§:;"-i 121 a 'Jeww.'xmyado<. rtiv Certified Abstract of Driving Record Inquiry Date: 5/22/2015 DL/ID #: 874AL5703 (IA) Name: Abdalla, Mohamed Class: D Address: 106 IST AVE Audit #: 9072752 Restriction None Issue Date: 05/09/2015 City/State: CORALVILLE, IA 522412602 Expiration Date: 02/24/2020 Endorsements: 3 Mailing Address: 106 1ST AVE Restrictions: NONE Date of Birth: 2/24/1976 Mailing City/State: CORALVILLE, IA 522412602 Sex: M History Information CLEAR DRIVING RECORD Name: Abdalla, Mohamed DL/ID: 874AL5703 Customer #: 6311770 ID Status: None DL Status: VAL CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: 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, mat 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 he set upon this document, at Ankeny, Iowa this date: .- ........ :�`�y 5/22/2015 IOWA 'WO Jam, F'BR@$= Office of Driver Services Iowa Department of Transportation Name: Abdalla, Mohamed DL/ID: 874AL5703