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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. l S — i ,� I
(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
Middle
2. Address (REQUIRED) �c'f4
sS
C01nl4j'lj€ /A SAA
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3. Contact Information (REQUIRED)
Email:
elu rel�-eW 6 97 6 ctF>7ril! -Corr)
Cell Phone: 3lq_ q&ll
(All written communicatiah sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
5, Prior experience in transportation of passengers: 6 7 C,0,r�
6. Have you ever been arrested /charged with any misdemeanors and/or felonies in this State or elsewhere? No
Type 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?
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? t\! 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
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CEATIFID + i
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE C90<11REMIEW
—3ti
You must apply for an individual Department of Criminal Investigation Report (form p,ypoFbrequM
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY tv
w
—_+ 02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that 1 have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
�j� K %fly issued ono c expiring on a a ' . I understand that if I
falsely answer any questions in this application, that this application may be denied. II gre�aking 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 TiXv-5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date 06 ,n "5'
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Fluocek-ec o I4- on this _24o day of
WENDY S MAYER ..I Nota v P -lic in an for the State 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). p {
Expiration date of Chauffeur's license IQ 0 t b 1 (2bt9
Q 7 o 1747
Signature of Pblice Chief or designee Date
AFTERAPPROVAL 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.
Signat&Te of City Clerk or designee
Approved application
DCI report
State certified driving record
Website update
C erkf IDRNBADGEAPPL92014amended.DOC 03/2015
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Office Use Only :—=Z
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C erkf IDRNBADGEAPPL92014amended.DOC 03/2015
Jun. 23. 2015 3:10PN D l v o` Criminal Investigation No. 140E P. 1
Fro,—, —, ..,we, —, OIerk -,_ -.v-,-.,_. 06/22/2016 14:4., x133 ...,02/002
STATE UP IOWA
Criminal Yrlipstary Re6C(brd Check
Request Foam
TO; lutaa MOSiop or Criminal Invesligatiot
Support Operaiiong Bureah, I" Moor
215 r, 7'h catrcet
Des Wines, Iowa 50319
(515) 725-6066
(5)5)725-6000 rax
I am revues inn an Iowa Criminai Hietniv fttcnnrrl Check nn'
DC'1Account Number:, 4Oo,;7--L —
(if applicable)
i'rom: C:isy ofluwa City _ __�_
City Clerk's Officc
410 r, Washington street -- — —
fowa City, IA 52240
Phone: 319-356-5041 _
Fax: 319-356-5497
Last Dame (mandatory)
First lupine (mandalorq) w
Middle Namit (recommended)
M o h441 ed
(f --L ��� e�
atil ro.SSQ
Date of Mrtb (manualory)
Gender (mandatory)
Social Securi • Number (recomm�ndea)
G —p1 _ 1 q—I5
f✓JNiale ❑Female
5/3- gq—eg6q
Wrtiver hiformalion: Without a signed waiver from thesubjeet ar(he request, a complete criminal history record may not
be releasable, per Code offowa, Chapter692.2. For complete criminal history record information, as allowed by law, always
obtain a waiver signature from thesubject of the request.
Wat'Ver Reietise: 1 hereby give pcnnission for the obpve regbcsting official to conduct an lona criminal history record cheek+Olh the Division of Criminal
Irmstl$alim(OCY), Any criminal history data conce 'ng me [list is maimaiaed by the DCl maybe released as allowed bylaw.
Waiver Signature
Iowa Criminal History Record Cheek Results
C :, (DCI use pul)I)
As of 2 1 a search of the provided name and date of birth revealed: {
t►,� No Iowa Criminal I-iistul'y Record found Hrith DCr
0 loyva Criminal History Record atca uht:d, DCI i/
DCI initialsivi-
1)0.77 (09/25/10)
Received Time Jun, 22. 2015 2,39PNi t<lo: 1271
Inquiry Date:
Name:
Address:
City/State:
Mailing Address:
Page 1 of 1
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ea, P` r v.r,f r 1irp •iV �7'ai.t(: YJ4 :..,.lie l.v+`�iav
..MA" CFR I riN I.sR I Ivi,1SWMER DRf4EN
Citfir�e of C+rivet Services
F1 Box 82041 Lies, `4orrpea, LA 5,0 .'2r
Phi 515-244-11124 i W: 32-i 12 I I. Fac 5 s:,_;y $g_1827
wA'J leyraoO, 0,),i
6/23/2015
Mohamed, Elwaleed
Mussa
106 IST AVE
CORALVILLE, IA
522412602
106 1ST AVE
Mailing City/State: CORALVILLE, IA
522412602
Certified Abstract of Driving Record
Dii #: 815AK6090 (IA)
Class: D
Audit #: 8156090
Issue Date: 06/11/2014
Expiration 01/01/2019
Date:
Endorsements: 3
Restrictions: NONE
Date of Birth: 1/1/1975
Sex: M
History Information
CLEAR DRIVING RECORD
Name: Mohamed, Elwaleed Mussa Dii 815AK6090
Customer #: 6231198
ID Status: None
DL Status:
VAL
CDL Status:
None
CDL Cert
None
Status:
CDL Med
None
Status:
Office of Driver Services
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, 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:
•• ��%•'rrr
6/23/2015
IOWA .W''/
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Office of Driver Services
Iowa Department of Transportation
Name: Mohamed, Elwaleed Mussa DL/ID: 815AK6090
6/23/2015