HomeMy WebLinkAbout15-138r ®ta7It.
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(3 19) 356-5497 FAX
1. Name (REQUIRED)
2 Address (REQUIRED)
IDENTIFICATION NO. ffF— 3 5
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDIC VEHICLE DRIVER
(Police Department review must be made betweeol6 p a.m. p.m., Monday — Friday)
ra lure to c9lnn?6re iee "re LLt P.— fl4formation wilt tesuft ldl denial of the apGifCa !2
3. Contact Information (REQUIRED) Email: N& -�) NAAcCell Phone:
(All written communication sent via' ail)
4a. Chauffeur's License expiration date (REQUIRED) Z� q 1) (0
b. Taxicab Business Name (REQUIRED, ^-0�%0'tn
�J
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? �V 0
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? (\% -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? t\j t%
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)
t\� fo
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)
02!2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
]IlL 0 2015
I hereby certify that I ave issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
] c" z n ii i t issued on -7 Jt<�piring on � �i i understand that if I
f laf iely n wer any questions in this application, that this app ication m y be denied. ogre 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 's Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Me,J;Nckimkr ) F_ (AI 6k— on this FAJA 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 Qitle 5, Chapter 2, City Code).
Expiration
license f'L
:� I �'�//Jl
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.
SignatLlre of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Da e
CIer6JrAXIDRNBADGEAPPL92014amended.DOC 0312015
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i�Yifi J' i.. ri .i fieE�L� 1i i 1.} � i� V.r�,.,'. �i�4 i �!ia2 • n.�.n .a :Yf Pv ... .th, _ .�,em:-�/—'S✓r`%%Vt
once of Firiver see vices
PO FrN, 3204 € Des t;Irines, f i Gi':f3c: 920,4
FN,1 :515-244 r124 ; POG -E32-1121 I F.s.' 5'F. -23u-1.637
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Certified Abstract of Driving Record
17/2015 DL/ID #: 257DD6818 (1A)
'ahim, Mohamed Elsadig Class: D
04 BARTELT RD APT 26 Audit #: 8263718
Issue Date: 07/16/2014
WA CITY, IA 522462714 Expiration Date: 09/02/2019
Endorsements: 3
04 BARTELT RD APT 21B 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:
'.12/04/2013
Conviction Dale
ACS&
Erplanation
Count
3L1R
08/28/2012
S92
_ ...
Speed
Johnson
n
IA �
111/06/2012
592
Speed
Johnson
IA
'.12/04/2013
M70
Improper Passing
Johnson
IA
ed 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
-rds 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.
re caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date:
SotiOc: ........v/vi
4/17/2015
IOWA `y4,
o
D. 0.T..`Wy
Officeof Driver eof Services
Iowa Department
;d Elsadig DL/ID: 257DD6818
1 u n 17.
2015 3:22PM
Div
of Criminal Investigation
No, 9200
t
2
Fro".:OicY
c1 Iowa
Ctty Clark
Ottic r• 31e 9686467
06/16/2015 14:61
0126
P.0021002
STATE OF IOWA �m �
d't-Etl final History Record Check
Request Form yG5
To; Iowa DiviSimi of Criminal lnvcscdgadoil
Support Qperatious Burcou, 0 Floor
215 k. 7"' Street
Des Moine,e, Iowa 50319
(515) 725-6066
(515) 725.6000 Fax
I sm reuuestine an lows Criminal f-fiafnry RnenrA Check nu,
DCI AcCowl(NfwnbeI'I C—jQZ?_62 —
(if applicobI.)
From:
�Clty Clerk's Office
410 r. VJa£hington 6Ereot
Iowa �E.VIA 52240_, _--
Phone; 319-356-5041
rax; 319-356-5497
Last Nalr/e m2ndnog9
Fjrsf N''ame (menmwy)
gflddje Name (recammended)
mph me
}'late Of )Rtrth (mmWalory)
Gender (mand:wn9
Social Security Number (reocmmend:d)
I
�Malc ❑female
Maber Xnformafiou: Wllhout a signed waiver from the subject of the request, it complete criminal history recard clay nal
he releasable, per Code of Iowa, Chapter 692.2. I'or complete criminal history record information, as allowed by law, always
obtain a waiver si na(uro from the subject of the i equest,
WQil'ei- ReieRse� I kicby give pcmdssioa roc the above requesting official to eondocl an lava criminal hislory iecotd cheek wil6 die Division of Criminal
lovaligaliou(DCI), Any criminal bislory data wIft .ngllrelhali maimeincd Ly tAe DCl may ec roleased ns sllawed by latr.
Wniver.Sigrrrtrul•e: ___________ — .---u���-^j-)�-%��,e _
Iowa Critnin.aI History Record Check Results tDC,t,sronly)
As of r—� l �1 _ a search of the provided name and dale 0f birth revealed:
Nn ]aura Crilt)inal InCislory Record found with DCI
❑ 10wa Crilli tial I-iislory Record attached, DO �.—�-----__-- �
DCI initials—�. W
tv
Received Time Jun. 16, 9015 9 44PM No DR91