HomeMy WebLinkAbout15-116� r
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 — / !(p
(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
2. Address (REQUIRED) /-'b 14-14 1 ';fi0y1 -'D) -1 CXcJckC-Ifit Q 5 2 2 f O
3 Contact Information (REQUIRED) Email: r✓/cA5c,, ?IA J&-hgtI (f2G MOLI _Cnr Cell Phone:l5Imo)
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 0/-29— O, 17
b. Taxicab Business Name (REQUIRED) (' j4 �Z
5. Prior experience in transportation of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
Where
When
ru
0
c�{ t
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty zfOFer ,y
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense Where ehen un
M
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?
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)
0212015
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
�D 857/ 7 issued ono2-2S•2rNexpiringono/-29_ 20 )7. 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 provisionsAf Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date 6 -4 -_2o/S
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by on this 94day of
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 orwelfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license 1 /2_&t� Ze��
Signature of Poli iso 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.
Signature of City Clerk or designee
Date
Q
Office Use Only *_:
2n }
z
Approved application
DCI
- t
a
report
State certified driving record
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a
Website update
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clern,7xiDRiveaoce PPL92014am.,ded.Doc 0312015
10WADOT
SMARTEN I SIMM R I CUSTO' rr DRIVEN, U"V Vitiowadot goo
Inquiry Date: 6/4/2015
Name: Musa, Mutwakil Mohmed
Address: 86 ANISTON ST
City/State: IOWA CIN, IA 522402216
Mailing Address: 86 ANISTON ST
Mailing City/State: IOWA CITY, IA 522402216
Office of Driver Services
PO Box 5204 ; Des Moines., IA 53306-92G4
Phone: 515-244-9124 1800-532-11211 Fax: 515 239-1837
wwa,.iowadol.gov
Certified Abstract of Driving Record
DL/ID #: 152DD8517 (IA)
Class: D
Audit #: 7820359
Issue Date: 02/25/2014
Expiration Date: 01/29/2017
Endorsements: 2
Restrictions: Corrective Lenses
Date of Birth: 1/29/1965
Sex: M
History Information
Customer #:
4550505
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
"'code. Date. _. Case ;.'umber ,yJR
09/28/2011 1649802...._.
IA
Sanctions
Type
Effective
End
mCD
Cxplanatioo
Occurrence JUR
JUR
Suspended
08/02/2012
.06/18/2013
D51
Non Payment of Child
Support
IA
IA
Suspended
..08/25/2012
:06/18/2013
,D51
:Non -Payment of Child
Support
IA
IA
Name: Musa, Mutwakil Mohmed DL/ID: 152DDS517
Pursuant to Iowa Cade §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:
Name: Musa, Mutwakil Mohmed DL/ID: 152DD8517
6/4/2015
c
Office of Driver Services
Iowa Department of Transportation
Jun. 2. 201h 4;32PM Div of Criminal Investigation ND, 9676 K $
Pro.i..a .y — . ,w- —, Jlcr u. 06/01/2016 13:10 saaae r.u021002
STATE OF IOWA
iCiriminal History Record Check
Request Form
To; tow» Division of criminal Investlgotion
Support operations Idurcaa, 1"I Floor
215 L. ?"'Street
Des Moines, Iowa 50319
(515) 725-6066
(515) 725-6090 Fes
1 am rem,&,tuna an lnV,A Criminal Hictmv Record Check on
DC1 Account M)mbcr: _(dc 0�-
(irapplicable)
Irroen: City of lows C'f-__
City 04009 Office
410 C. ExJashin fon SFrdef
Iowa Cifv. IA 52240
Phone: 319-356-5041 _
Fax: 319-356.5497
Last Name (mandator))
First Name (nsaodatory)
]Middle Naanc (recommended)
Date of Birth (mandatory)
Gender (mmndamry)___
Social SecurityNumber (recommended)
/�� �' �9GS
ale ❑Female
��/ 76 _�qL
Waiver Information Without a signed waiver from the subject of (he request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2. For comoletc crltnfnal hlsto•y record imfarmation, as allowed bylaw, always
obtain a Wak'er signattme 11am Che sabjecl of fie request.
„�
Plalver Release; I hereby give permission for the abova requesting official to conduct art lows criminal history record check wi0, the Division ol'Criminal
LrvesGgatinn (UCQ, Any criminal history data concerning roe fll is mainlaLre �Isel)Clniv released as allowed by law.
w(river.Slbnature. _ _ _k/�)�-� Jp� '
Towa Criminal History Record Check Results PSI use only)
//� �^ ell
As of l e a search of the provided name and date of birth revealed;
No Iowa Criminal History Record fouad wi(h DCI 7 <` ��
N
® lovva Criminal History Record attached, DC4P.l !# r �
tr
DCI initials .
DO -77 (08/25/10)
Received Time Jun. 1. 2015 1;10PM No.9435