HomeMy WebLinkAbout15-135CITY 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
f5-135
(Office Use Only)
APPLICATION FOR TAXICAB I 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
First
2. Address (REQUIRED) S o 4 6v+Pl —
3. Contact Information (REQUIRED) Emailvim` y )aPZ a[�o nkco - < o •h Cell Phone: 3%5
(All written communica 10 sentema
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
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?1�
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? N O
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? 00
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)
N0
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
9�_0 A L_39 � 0 issued on obtXb);Z iS expiring ons*la6j 2ol, . 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 provisions of Title 5,.,Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date o �� xo f
STATE OF IOWA )
COUNTY OF JOHNSON )
Suhscril and sworn to before me by f" - AU4-141 on this E) ✓; I day of
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 C eur's license
gnature of Police Chief dl,,designee D te-
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.
7f l t 7A4
Sign ture of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
715 -//5 -
Office
/5 -
ClerkrrAXIDRIVBADGEAPPL92914.m.,ded.DOC 0312015
Jul. 1. 2015 2:45FM Div of Crlminal Investigation No.0125 F. 1/2
From,:UIry pI Iowa Ctly Clerk 0111Cte 312 3666497 06/29/2016 14:42 0130 P.002/003
STATE OF 10WA
Crillmma6 History I1ecol°d Check
Request Form
TO: Iowa Division of Criminal InVi Etigatiou
Support Opera fions ISurean, 0 Flaor
215 k, 7'h Street
Des Aloines, Iowa 50319
(515)'77,5-6066
(515) 725-6030 Fq),
I am f'Mi CS011P an lOwu Criminal NiUniv kecnrd Cheek nm
DCI AccoUn( Number: 700 - r—
_,._. -(if applicable) ---•-
Fronm;--
City Clerh's office
410 F. Washington Street
Iowa City, IA 52240
Phoue: 319-356.5041
Fax: 319-356-5497 -..•-"__._--_,..._w.._�_
Last N: 2d le (mandaloq') Fil-st Name (mandato ) _ Middle Narao (remmmended) _
ca11Qo�nk nw eG1�j'ra�e�
Date of Birih (mandalory) Gender (maneamry) Social Sccuril �Number (rerpmmodtd)
U (i 1 al QMale Criernale
A'ail'0 InfOrn4aliWI: Without a signed waiver from the subject of the request, a complete erlminel history record may not
be releasable, Iter Code of Iowa, Chapter 692.2. For complete ei iminal Ilislory record information, as allowed by jaw,always
oblain a waiver signature from the Subiccl of lbe reUuest.
Mulver Release: I heroby give permission for the above requeslurg official to conductan Iowa criminal history record check wish ila Division of'Criminal
Inrestiyatiml (DCQ,
Any criminal huiory data concerning n¢ deal is ma'mained by ere DCI maybe released as allowwd by law.
13/
atvcrSi�nature:—
Iowa. Criminal History Record Check Results
As of _ Vi i__, a search of thepyovided name and dale of birth revealuli
:.
No Iowa Criminal hiistor)r Record (bund wills 1JC1 "Li '
❑ Iowa Criminal HisloiyReccrrd attached, ).)CI ll
DCI initiels_--.-____,__
keteivtd Tim¢ Ju6.29, 2015 2:35PM No. 1825
(pca use only)
�4UWA DOT
SMPTIR 151MFLU I CUSTOM -EF: DIRN N WU'd viCti/Vadotgov
Office of Driver Services
PO Bao 9204 1 Des Moines, to 50306-3204
Phone. 515-244-9124 j 800-532-1121 { Fax: 515-239-1837
wwvo towadot:gav
Certified Abstract of Driving Record
Inquiry Date:
6/26/2015
DL/ID #:
92oAL3980 (IA)
Customer #:
6376079
Name:
Abdalla, Mohammed
Class:
D
ID Status:
None
Mustafa
Address:
2504 BARTELT RD APT
Audit #:
9203980
DL Status:
VAL
1D
Issue Date:
06/26/2015
COL Status:
None
City/State:
IOWA CITY, IA
Expiration
11/04/2020
CDL Cert
None
522462714
Date:
Status:
Endorsements:
2
CDL Med
None
Status:
Mailing Address:
2504 BARTELT RD APT
Restrictions:
NONE
Restriction
None
1D
Date of Birth:
11/4/1985
Supplement:
Mailing City/State:
IOWA CITY, IA
Sex:
M
522462714
History Information
CLEAR DRIVING RECORD
Name: Abdalla, Mohammed Mustafa DL/ID: 920AL3980
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:
•...... y�l
6/26/2015
IOWA
C41"
f BRIY4N $
Office of Driver Services
Iowa Department of Transportation
Name: Abdalla, Mohammed Mustafa DL/ID: 920AL3980