HomeMy WebLinkAbout15-137_ n•l t 1
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319)356-5040
(319)356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO
oT-15-7
(Office Use Only)
APPLICATION FOR TAXICAB! MOTORIZED PEDIC VEHICLE DRIVER
(Police Department review must be made betwee9;18 a.M. p.m., Monday — Friday)
Failure to complete the "required" information will result in denial of the application
3. Contact Information (REQUIRED) Email: iV�tSYVX.tiyter�3 ;� Hs�� Cell Phone:
(All written communication sent via ail)
4a. Chauffeur's License expiration date (REQUIRED) )0 :�� I/ '2(0 1�
b. Taxicab Business Name (REQUIRED. _ ^ `t Gly r aAl)
5. Prior experience in transportation of passengers: h - -e,"^<
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
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? %t ^S
Tvpe 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?
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)
tJ /o
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
JUL 91015
1 hereby certify thatMe e issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
ii Zw r issued is %t�a lbe inn on cl I understand that if I
f laf sely n wer any questions in this application, that this app kation m y be denied. agre that in ma ing 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
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by =inT-I �.ak— 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).
Expiration
license
�I
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.
SSi nat e of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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clerkrrwaoRroeaoc�PL92014amended.Doc 03/2015
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Office of C•rivuf se[vic�s
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Certified Abstract of Driving Record
17/2015 DL/ID #: 257DD6818 (IA)
'ahim, Mohamed Elsadig Class: D
04 BARTELT RD APT 28 Audit #: 8263718
Issue Date: 07/16/2014
WA CITY, IA 522462714 Expiration Date: 09/02/2019
Endorsements: 3
04 BARTELT RD APT 28 Restrictions: NONE
Date of Birth: 9/2/1979
WA CITY, IA 522462714 Sex: M
History Information
Customer #;
4350508
ID Status:
EXP
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status
None
Restriction
None
Supplement:
112/04/2013
Conviction Date
AC3
Erpianation
County
3[i32
:08/28/2012 -.
592
Speed
--Speed
- Johnson
'IA
11/06/2012. ---
S92
-'.M70
- - -
- Johnson
IA
112/04/2013
-Improper Passing - _
- Johnson
.IA -
ad Elsadig DL/ID: 257DD6818
.321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I am
Ards held by the Office of Driver Services, that this is a true and accurate copy of an official record currently in the custody of
ve been authorized by the Director of the Iowa Department of Transportation to so certify,
ie caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date,
'•y.'�'/phi/
4/17/2015
IOWAi
f OBER 4
I
Office of Driver Services
-
Iowa Department of Transportation
A Elsadig DL/ID: 257DD6818
Jun.11.
2615
3�22PV
Div of Criminal investigation
N o . 9
2 0 0 P.
2
F<o M:CiXv
of Iowa
�I�q —
City
clerk Office 31fa 3686487
06/16/2015
14:61
obtain a waiver si na(uro from the subject of the request.
0126
P.0021002
STATE OF 10VVA
Criminal �'iistary Recovd Check
@RequeA Fom
To: Iowa D ivision of Ce ill) ilial hrveaigstion
Sapport Qperaeious Bureau, V Floor
7,15 l✓, 701 Stl-cot
Des IVfoitees,Iowa 50319
(515) 725-6066
(515) 725-6000 Fax
I am reouestine an lc)wa Criminal History Record Check on:
F
DCl Account 1h!umber,
(itapplieuhlc)
From: fafV of f otva City _,_...--------------
�Clty ClerlA office
410 f. WxshingtonStreot
Iowa City. JA 5214()
Phone: 319-356-5041
Fax: 319-356-5497
Last Name mandatory)
First game (nandouiy) -- _—_-
Middle Name (recommended)
Date of Birth (romldalgry)
Gender (maod%op)
Social Security Number (reeen,mended)
�I�q —
Male ❑Female
Waiver Aformation., Without a signed waiver from the subject of the request, a complete criminal history record map not
be relessahte, Per Code of lows, Chapter 691.2. For complete criminal history record information, m allomed by taw, always
obtain a waiver si na(uro from the subject of the request.
w
{d'aiver )teieare I hereby give pcmJssion For the above aqucstiog o0i621 to conduce an Iowa criminal lwlery retold check Willi the Division dcrimium
Invecugalion (PCI), Any criminal hilWr)l data wncerningme Thal i mainrenmd bq the I1Cf mol' be releasin ns ellou'ed by Imr.
`` I '
Waiver Signature,
lulkila e-IFltI11114I-"" IV Cy Ji`I'.l':VIU %—HUIUh. Arl."UItb (DCI list only)
As of 1 i1 �� _ a search ofthe. provided name and date of birth reveak"d:
- -1
F,. �t^l
No Iowa Criminal Hislnhy Record found ivilh DCl
❑ lows Crjlninol 1-listohy Record attached, DO
Del initials__ _ Iv
M 1-77 (U/25/I0)
Received Tirre Ju n, 16, 9015 2'44PM No.0891