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Home My WebLink About15-124IDENTIFICATION NO. 14,5— ) r;�I 7 1 P 1 (Office Use Only) dlll� APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) 410 East Washington Street Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (3 19) 356-5040 (319) 356-5497 FAX First Middle Last 1. Name (REQUIRED) / WQ S AI je to S � L y, SLS { F I �A �t t 1 n14. 2. Address (REQUIRED) 3. Contact Information (REQUIRED) Email: 7 C5 �'1Q 1z 2c> Q0 �t yvnc . 1.. r .. Cell Phone: � � ; ��i; (All written communicatiM sent via email) -'T7 7Z7Tc I r tela 4a. Chauffeur's License expiration date (REQUIRED) cr 17= b. Taxicab Business Name (REQUIRED) _ Iga�I—t int �4 h 5. Prior experience in transportation of passengers: 14 F� bh i 1 A d LL VC - 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? IV Tvpe 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? A f 6) 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? y.i Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pr ie thezarne.La . /0 DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND ST DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLIC You must apply for an individual Department of Criminal investigation Report (form (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) upon request). .0 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 h /� I d R- - 7 issued on a .expiring on a � . 1 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,fC4apter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant _- ,�^=' Date ��,�iq u` STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by I.)oc�r_/�_ h. Mel a4a.2 on this _ 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). license of Police' @Yfief or 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. Signaturd,of City Clerk or designee ` to clerk/rAMDRw6ADGF PL9201Aamended.Doc 0312015 a Office Use Only C --fig + 7 Approved application � �� ni DCI report —<r - r State certified driving record Website j s update to clerk/rAMDRw6ADGF PL9201Aamended.Doc 0312015 F Jun• 4. 2015,11:26AM,,.', iv c Criminal I n v e s ' i g a t i o n l 1 /,r54t WA J oelf,aW�YCiriminal History J. Record' Request rm To: Iowa Division Df Criminal lnvesftation Support Operalions uoresn, Ir' Floor 215 C. 71h street Des A4ohaes, Iowa 50319 (515)725-6066 (515)725-6080 Fax I am reouestine an Iowa Criminal l3istory Record Check on: 06/O2/2016 16:eNo• 9895;,0-1F 1121:/002 ,, r DCI Account Number: (if aPAlicablc) Front : _ City of Iowa City - City Clark's office 410 E. Washington Street lows City IA 52240 Phone: 319-3.56.5041 Fax: 319-356-5497 Last Name (mandatory) First Naffie (mandatory) Middle Name (.eram,,endad) As of > a search of the provided name and date of hirlh revealed: _ g Date of Birth (inandarory) Gender (mandatory) Social Security Nualber (reomnmcndea) "If -Jill 1996 1�13I12ale ❑F+emalc �t - 5'? -d 56 Waiver Inforrnatiogl: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For com tete criminal history record tnformatieh, as allowed by law, always obtain a waiver signature A'oin the subject of the request. Wal ver Release: 1 hereby give pem,ission Cor the aboyc requesting official to eondua m lona eritninol history record check with the Divition of Criminal 11-5tigstion (ACI), Aly, criminal hislory data wnueruing me that is mninianrod by um DCI may he relented as allowed by Ian•. Waiver sips ature: Iowa Criminal History Record Check Results (DO list anly) As of > a search of the provided name and date of hirlh revealed: g _4 " rr I�10 Iowa Criminal History Record hound with DCI t— r.,,,,, ^t gar" C+i t ,y ;OCA Iowa Criminal History Record altached, DCI --- z DC1 inilials_�__ I— I� DCI -77 (08/25/10) Received Time Jun, 2 2015 4:25PM No -8499 4il10WADGT SM,ARTEtR I51WI°mr: i USTOW' DPiVE:d . OWc�[� G, 3V Office of Driver Services PO Box 9204 $ Des Moines, rA 513-106r9204 Phone: 515-244-9124 1800-532-11211 PaK.: 515-239-I,?37 Wvm_kmadot_gov Certified Abstract of Driving Record Inquiry Date: 6/2/2015 Eli #: 5B2AH0582 (IA) Name: Mohammed, Nasr Class: D Aldden Osman Oshar Address: 2401 BARTELT RD APT Audit #: 8142283 28 Issue Date: 06/06/2014 City/State: IOWA CITY, IA Expiration 01/01/2017 522462701 Date: Endorsements: 3 Mailing Address: 2401 BARTELT RD APT Restrictions: NONE 2B Date of Birth: 1/1/1980 Mailing City/State: IOWA CITY, IA Sex: M 522462701 History Information Convictions Customer #: 5930422 ID Status: None DL Status: VAL CDL Status: None CDL Cert None Status: CDL Med None Status: Restriction None Supplement: CUation Date...... Conwictioa Data...... ACD Explanation County .1i9R 01/25/2015 :02/12/2015 M70 Improper Passing Johnson IA Name: Mohammed, Nasr Aldden Osman Oshar DL/ID: 582AH0582 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: P: """••'r/'L 6/2/2015 10WA°�4 D. 0. T.' 92F 6.... $�' Office of Driver Services Iowa Department of Transportation Name: Mohammed, Nasr Aldden Osman Oshar DL/ID: 582AH0582