HomeMy WebLinkAbout15-171IDENTIFICATION NO
15-n
(Office Use Only)
C) OF 10WA CITY APPLICATION FOR TAXICAB! MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m, to 3 p.m., Monday — Friday)
410 East Washington Street
Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(319)356-5040
(3 19) 356-5497 FAX
First/� ` Middle st
1. Name (REQUIRED) r' 1C�1Aj Q I t %� A r��p�� t a C t
2. Address (REQUIRED)
3. Contact information (REQUIRED) Email :�AIJkwritten�cornmunica�tiori—se
—) \c1� ('-
etYR�hone:
t via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) _ ("I , ( ' `j r) two
5. Prior experience in transportation of passengers:
r--
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or=e1§Ewl1-rP9 'n
Type Of offense = "N � — —
Where When
C rI
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? Yftr
Tvpe of offense
S na�A
What happened to the charge? (Circle one)
Where
\ 01^
& to
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
1
8. Has your driver's license or chauffeur's license been suspended or revoked in the last fiveears?
Y
Type of offense Where
When A(d
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
A/m
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
I hereby certify that I have issued to me by the Iowa Departynent of Transportation a valid auffeur's license number
— 5%A �S 1 F, 2 I, issued on - J2b) ' expiring on 1 �" � . 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, an urther agree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions of Title 5,a�of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant
**#******##*##**x*##k********x##k*****#**#x*****####**#*###****##***#**#*k***###***#***####******###**#***x####k##***x***#***#* ***x*##********
STATE OF IOWA )
COUNTY OF JOHNSON ) pp
u scribed an J
sworn to before me by �r7hie�in (Lo -'s on this day of
AQ 4
1
KELLIE K-TUTfLE
�'rl ('omm n rasionlE 2P1819 at `
�;onFxpires Notary Public in and for the State of Iowa
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 Chauffeur's license
r
Signatu e of Poli hief 6r designee —mac 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.
Signati1mof City Clerk or designee
*-fl4/��D to e
**x#h#***xxxx#*k*****x*xx*#*******x*x##x#*******x*####******x#####****k*kxxx#*#*******xxx##}******x#xx##*#****xx#*#*******xxx##*A##***tx#*******
Office Use Only
Approved application
DClreport
State certified driving record
Website update
Cleo-✓ MDRivBADGFAPPLM14a ,md� DOC 03/2015
Aug.14. 2015 4:45NV Div of Criminal Inveetlgdt10n No.316S P. 51
Flo �n; viry U. iowm guy cl.',, ' 'T.De %$1w JG Go6N/ 02/13(2.016 14 33 020e P.tiO3/o03
0 Request fi'ernl
Crfm6nlat Hi'.stot-31 JzE.eOrd (w'ilecf�
IMI of Criminal h,vextiga flan
`sulrporf C}perafious' RUYPa u, 1"Y'lu ey
215 E. 7" 9lrccl
1Des hf obacx, love 5(1319
(515) 725-6065
(515)725.6080 Fax
Record
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I'rvfl: _ Ciqut laws �
Chy Cleric's OiT�r `--�- - -
4T 0 E, iVasll! (on Street —
Phoue: 515-356-5041 ---.._�.---.--
Fax: 319-356-5451)
.w sr s�aIIlC (mandatary)
---�- AZiddle�TahlC frowmnundw) �_�_
Date o-- f T3iYf�h rmnnaeiup'>
Crehder (maneararl-) Social Secnrit
�'—"—�' I'�Uh)ber (recommended)
e releasable,
able, per C, do fVj(haat E sign waiver from tllc subject Of the request, a conlplele crtsninal i istory record play qdl D
be releasable, per Cadc of Chapter
Chapter 692.2, For comle(e criminal history record information, as al> /owed by )eH,�}
obfaiu a waiver si nature /rom the sub'eef of (here uost.` _
ay_
I'%�RfVEI',�iC[cQSCr I Lercp}give },omission for lAe above
me 111 h
mgtleslin official In condom a7 lc wa criminal rlars� record check4'
���'�'
Invcstiearion /DCI). My criminal hislwy data wncernin
nraincd bydm DC) may he released as allolred by law, Mo -n of
1f'rri,lcr,yragR/rne —°:
M of
a searcl) of the provided llamee and (Jule of birih revealed
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]uwa Gruuigal I�is(oq' ]tecbre9 attached, 1707 9
172'1 ill ililals_
I)C:1-77 (OV25/10) - -
0 1'�10 k)v>,'a ('rin)inal History Record fo lmd ll -All J)CI
4,,.1
Received Tlme Aug 13. 2015 2:25 PM No 5512
UP(A 'Se only)
3,
C410WADOT
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SM?R(En 1 S If;fLr_i{ ILll}CCbtn t kbVci
Office of Driver Services
F-71 Box 9204 1 Des Manes, IA_ 503OC-9234
Fha.^.e'. 515-244-9124;8 Cr532-i12t 1Parr. 515-239-1837
;trww_-awadot_gov
Certified Abstract of Driving Record
Inquiry Date:
8/19/2015
DL/ID #:
832AK7321 (IA)
Customer #:
6258178
Name:
Yousif, Mohieldin
Class:
D
ID Status:
None
04/09/2015
Seedahmed
S92
_
Speed
_
Johnson
IA
Address:
2502 BARTELT RD APT 1C
Audit #:
8327321
DL Status:
VAL
Issue Date:
08/06/2014
CDL Status:
None
City/State:
IOWA CITY, IA 522462713
Expiration Date:
01/01/2019
CDL Cert Status:
Nave
Endorsements:
2
CDL Med Status:
0
fie
Mailing Address:
2502 BARTELT RD APT 1C
Restrictions:
NONE
trlictioemenn't
fff7oi�e
Date of Birth:
1/1/1958
SResupp
C.
�
Mailing City/State: IOWA CITY, IA 522462713
Sex:
M-
--°i'
History Information
cn
Convictions
—�
Citation Date
Conviction Date
ACD
Explanation
County
JUR
10/28/2014
11/19/2014
S92
Speed
Johnson
'.IA
04/09/2015
05/04/2015
S92
_
Speed
_
Johnson
IA
Name: Yousif, Mohieldin Seedahmed DL/ID: 832AK7321
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:
a; •""••?sj�"grr
8/19/2015
IOWA`:_',
1 r
D. 0. T.
fF RRIVtR�d�
Office of Driver Services
Iowa Department of Transportation
Name: Yousif, Mohieldin Seedahmed DL/ID: 832AK7321