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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. ) 1 9
(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
First
3, Contact Information (REQUIRED) Email:
(All written communication sent
Last
Cell Phone:
O 2
4a Chauffeur's License expiration date (REQUIRED) C / - c I - / R
b, Taxicab Business Name (REQUIRED) 3�if
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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? Iq/ l>
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other ; V
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? 4z 40
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 STATii�D
EVI*'
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE 1 REW ,�,�,,,
e"-9, N
You must apply for an individual Department of Criminal Investigation Report (form avaiupon-- request
M.
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(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY¢,„`
O 0212015
00
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certi that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
G l 22� b issued on D2-13-13 expiring on 0/-e,' - ZI8 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
STATE OF IOWA )
COUNTY OF JOHNSON )
S bscribed
and sworn to before me by
tnov
this
day of
Approved application
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Iowa 1Nil
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 orwelfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license
Signature of ief 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.
Signature of City Clerk or designee
Office Use Only
K-,2-7 -
Date
Q
Approved application
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DCl report
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State certified driving record
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Website update
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CIerkrrAXIDRIVBADGEAPPL92014amended.DOC
03/2015
Aug19. 201'1 10�03AM D l v oI' C r i m ! n a 1 iovesti,ation No, 3476 P 1/6
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STA" R' CSF ICS"IA
C'rimhialffisforp Record che(,I(
Rt; quest F'ornI
IoWa Division of Criminal Iln es(iga liun
5np11ort Operations Bureau, I" Floor
215 B. 7'4 Street
Des Moines, Iowa 50319
(515)725-6066
(515) 725-6000 Fax
1 am requestinC au
Date of Birth imanaaloq•)
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City Cleric's office
410 L', WAs1lin tan 36rect
I0maa City, IA 522411
Phmle! 319-356-5041
Fax: 319-356-5497
Omale ❑Female
Number
w'arve!' Lnforfnalloll. Without a signed waiver from (he s bi ee( of 01 re.ques t, a complete criminal history record may ilal
be releasabIC, per Codc of Iowa, Chapter 692.2, For comate erinlinal history record Information, as allowed by law, always
obtain 9 wiiw, fiun nlu✓n c—, .6 ............. -♦IL- --.._...
WoriveY Release: I heaby girt perosission for lilt a6overaquaslmg official m col,ducl 21110-6 criminal history record eheek wish the niriaon oroinr,lal
Invtslioatoo (DCI). My crilnina) his ory dn(n emceming me Ihsl i5 mainleined ty IIIc OCI may be released si .911o,rcd by Ian.
n
i'1'ainer Si; Half:re:
go{via crilrlinal Ifistor Record Check Results
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(OCI1st „I,)
As of .—__ 5 \ 6,LS, a search o the plrovided name and date of birth revealed:
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No Iowa Criminal History Record found with DCI
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i'ri I SPriR[q I CUSTPOrER DRIVER
Office, of Driver services
SPO 6or,. 92041 Deas Mj,nes, lA HsK6-9204
Phone. 515-244-9124 i 800 -532 -?121 1 Pao'- 515-239-1837
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Certified Abstract of Driving Record
Inquiry Date:
8/19/2015
DL/ID a:
669A72746(IA)
Name:
Mohamed, Mahmoud
Class:
D
Address:
5659 KIRKWOOD BLVD
SW Audit 9:
6692746
APT
Issue Date:
02/13/2013
City/State:
CEDAR RAPIDS, IA
Expiration
01/01/2018
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524045293
Cate:
Endorsements:
3
Mailing Address:
5659 KIRKWOOD BLVD
SW Restrictions:
NONE
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APT
Date of Birth:
1/1/1977
Mailing City/State:
CEDAR RAPIDS, IA
Sex:
M
Name: Mohamed, Mahmoud DL/IO: 669A72746
524045293
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History Information
Convictions
Customer 7t:
6063417
ID Status:
None
OL Status:
VAL
COL Status:
None
COL Cert Status:
None
CDL Med Status: None
Restriction None
Supplement:
O f ntiarr 0 ttv Ccawcban 0-41s f1cD Exp9a'I'lJon County 3UR
07/04/2013 07/29/2013 593 Speed MD
Sanctions
`Ty C s:f.iet I:nd ACD . nl-naoon occurruscas 1LFi JUR
Suspended 02/11/2014 ,07/06/2014 Fail to Post Security for an Accident Owner Only IA 'IA
Name: Mohamed, Mahmoud DL/ID: 669A32746
Pursuant to Iowa Code §321.10, 1, 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 he set upon this document, at Ankeny, Iowa this date:
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Office of Driver Services
Iowa Department of Transportation"
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Name: Mohamed, Mahmoud DL/IO: 669A72746
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