HomeMy WebLinkAbout15-140"rt.Y111_
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. 1 r—I F dl 0
(Office Use Only)
APPLICATION FOR TAXICAB 1 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
r r v a WVt to
2. Address (REQUIRED) !✓4_� blN� <,i' i-
3. Contact Information (REQUIRED) Email: �� S� i alYrtl4�-Zm Cell Phone:C3\h)Cl3i� g\A�
(A I written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) d'777 ' 3 f 29-
b. Taxicab Business Name (REQUIRED) _ J-9 Wao
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? 'j6/"C2—
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? _Z 42
i
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?
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)
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)
0
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
issued on expiring on . 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_wz_bL7.1 6?
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 11V1 c�. uccy- V A A A 1r on this l 7 day of
I 'i k�=j -YDty ,
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).
1/
Expiration date of Chauffeur's license
Signature offPP e Chief or designee 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.
igna of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
cienkrtAXioRivenoGEAPPrszoiaamended.DOC 03/2015
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cienkrtAXioRivenoGEAPPrszoiaamended.DOC 03/2015
FrcJul, llj. 2015,,,11:48ANi,, Div of Crlmina� IPvEstlgdti0n 07/09/2015 2 CNo.2778 6OP. 2/2/oa1
STATE OF IOWA
Criminal History Record Check
Request Fornf)
ye tee
're: town 1. visiau of Criminal Invesdgatinn
iupporl Operadoos Bureau, 1" Fluor
h15 E. V street
Res Aloinas, lawn 50319
(515)725-6066
(516)725-6080 Fax
1 511] reouest1112 911 Iowa ('riminal Nieln" R a""l 01—U
1701 Account Number:
pion: CM, f
City ClorWs office -- — ----
A10I[. Washing[an;ytrccl-_---��
lolva LL"ice �p 52240-----�--�
Phone: 319-366-5041
Fax: 319.356-5497----�—�
Last Mame ppand310 Y>
Ad-cl�0' -
First Name (mandaicp') _ —
Middle Name (recommended)
��
Date ot}3irth (mandatory) Gender (n,andmory) Social Security Number
/n(feco)"mcodcd)
6 PNIale ❑Female 7 _q
4lrrltver rfxfpi'MinfiON: Without a signed tvalver l5'om the subject of the request, a complete criminal h(slory record may not
be releasable, per Cade of lova, Chapter 692.2. tear com tete criminal history record information, as allowed by tae', always
Obtain a watvcrsi mature from the sub cel of the re uest.
Y'Ohler ]fe/e(186r f hereby give permission for rhe above req„csun8 official to conduol m lcoa criminal history record check wish ihr Division of C'rimiiml
Imezligalioufl)CI). Any criminal history data co can>gf&t lhar is main,ained py the llCLnay be released ns allow cd by lain.
Waiver siaA allily'
v � �
(PCI use onl))
AS of ,.._ Q a SCerC]] f1l' 111C ])1'C11'ldCd Ildl]]C and dGlc OCI>ltll] fC1'CajC(;i,
No Iowa (';ri,ninrll ldistur), Record found with DC:]
c,
a -�
•�:�
❑ lolva CS-in]inal History )tecord attached, 1)Cl
DCI inilials
DC] -77 (08/25/Ill)
— --
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—
Received Time Jul. 9. 2015 11:59AW Nlo.2646
Page 1 of 1
�IUVVA DOT
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Office of Driver Services
FO Soy, 9204 1 Des MoFnes. 1.4 50306-5204
Fhore. 6'.5-244-91 24 k 800-632-1121 i Fax: 515-339-18837
*'W,Y iowauo; got'
Certified Abstract of Driving Record
Inquiry Date:
7/8/2015
DL/ID #:
126AC0752 (IA)
Customer #:
5227858
Name:
Abdalla, Morwan
Class:
D
ID Status:
None
Mohamed Ahmed
Address:
1437 FRANKLIN ST
Audit #:
5493288
DL Status:
VAL
Issue Date:
09/07/2011
CDL Status:
None
City/State:
IOWA CITY, ]A
Expiration
07/13/2016
CDL Cert
None
522402710
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
1437 FRANKLIN ST
Restrictions:
NONE
Restriction
None
Date of Birth:
7/13/1968
Supplement:
Mailing City/State: IOWA CITY, IA
Sex:
M
522402710
History Information
CLEAR DRIVING RECORD
Name: Abdalla, Morwan Mohamed Ahmed DL/ID: 126AC0752
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:
p:.......:.A 1,
Q
D. 0. T.:�
fF Bfl14Ed r
7/8/2015
Office of Driver Services
Iowa Department of Transportation
Name: Abdalla, Morwan Mohamed Ahmed DL/ID: 126AC0752
7/8/2015