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HomeMy WebLinkAbout15-125a 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. IS -)o-7,5 (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 FI rst 2. Address (REQUIRED) ? _�Z� ,a 3. Contact Information (REQUIRED) Email: Middle 'TAT— z C / t� 1.v4 �-/A,eJ�A't(- nication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) n X —_., -7 b. Taxicab Business Name (REQUIRED)_ of - k—„ C-,>_�� 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 What happened to the charge? (Circle one) Where When Convicted Dismissed Deferred 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?� Type of offense Where 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please When DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATRT�ED ITr DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE F REVIEV� You must apply for an individual Department of Criminal Investigation Report (form available up n 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 1468 issued on)�� _Zo expiring on a A z. �� understand that if I falsely answer any questions in this application, that this application may be denied agree that it 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 (�' 6 / I i STATE OF IOWA ) COUNTY OF JOHNSON ) Subs ribed and sworn to before me by l�f© f�Ei/Ll�cXctrvz r on this day of KELLIEK. TUTTLE ° � V'�. Ccmmiao.on ^lumber 221 in and for the State of Iowa 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). of J�tauffeur's license 14 .� /D-1 r or desionee Date AFTER APPROV,BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO MORE THJ O YEAR FROM THE DATE LISTED BELOW. Website update aerwrazioRiva DGr PPL92014am.nded.DOC 03/2015 SigZj of City Clerk designee Date 0 k*kkC cn 4"'. ...,,, Office Use Only -HC) o }M�.� Approved application .a V DCI report ro State certified driving record Website update aerwrazioRiva DGr PPL92014am.nded.DOC 03/2015 Ju.o„ 3. 2015 3:55PM Div o1 Criminal Investigation No.9(95 P, 2/3 1'--K I''.-." - ...N- -..y ._dark —_-.- -+..• 06/02/2015 1213- -ton . ,.-..._/002 Q,bor Di rLo,k, STATE I " r<tyi e , ffistoryRecord c ( is Request Form I To: lowa Divlsion of Criminal Invedtigaiian S uppoet Operatimis Bureau, PI Mar 2,I5 L. `ill' Street Ides A9oines, lowa 50319 (513)735-6066 (516)725-6080 FAX 1 am requestiue an Iowa Criminal History Record Check ow DQ Account Nwnber: — (if'applicnblc)�� From; City of Iowa City City Clerk's Office 410 F. Washington Street Iowa City, IA 52290 Phone 319-356-5041 f w 319-356-5497 -- Last Name (n,andawy) Tirst Name OnaddaloM Middle Name (rtcDynwndcd) d CJ Date of Birth (Mandatory)µ Gender (mandalofy) _ Social Security Nuhaber (taomreendcd) 0 4Wlale ❑Female _ Waiver Xnforraafion: withou(s signed cvaiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 697,1. For complete cilmival history record information, as allowed by iaw, alvvays ohtsin a waiver si nature from the sub ect of the request. Waiver Release: I hereby givr, pmnission ror rhe abocc (cryacsting Official to conduct w loon criminal history recwd check ,rile the D;yisivn of Crhuinal InvcstigMion (DCI). Any criminal hisloiy dela wnce(oing me thal is mhiwaioed by lite DO may be relwed as allowed by law, waiver Signature: ( _ � e a.:.�.� r�: �_ • % Iowa Criminal History Record Check Results (nCl uze onl)) As of __— �p�� a search of the provided name and dale of birth revealed: vi ter.. No lova Criminal history Record found with I)Cl 7.5 .� 7U Iowa Criminal History Record attached, DC1 # GJ y - DCl initials_ DCI -77 (08/25/10) Received Time ,tun. 2. 2015 IM7PM No,9574 ,2jUVVj0r ,, n0T SMUTER I SIPAPI-H I M)TO+r"EF DRIVEN VVWW.iowadotgov Office of Driver Services PO Box 9204 Des Moines, 1.4 50306-9204 Phore:515-244-91241800-532-1121 I Fax. 515-239-1837 wwwiowadot gov Inquiry Date: 6/10/2015 Name: Mohamed, Noureldin Adam Osman Address: 2530 BARTELT RD APT 2C City/State: IOWA CITY, IA 522462719 Mailing Address: 2530 BARTELT RD APT 2C Mailing City/State: IOWA CITY, IA 522462719 Certified Abstract of Driving Record DL/ID #: 913AL1908 (IA) Class: D Audit #: 9131908 Issue Date: 06/02/2015 Expiration Date: 01/01/2020 Endorsements: 3 Restrictions: NONE Date of Birth: 1/1/1972 Sex: M History Information CLEAR DRIVING RECORD Name: Mohamed, Noureldin Adam Osman DL/ID: 913AL1908 Customer #: 6314142 ID Status: None DL Status: VAL CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: Iowa Department of Transportation 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: """..74% 6/10/2015 IOWA *wt D. 0. L fts 'B£ Office of Driver Services Iowa Department of Transportation Name: Mohamed, Noureldin Adam Osman DL/ID: 913AL1908