HomeMy WebLinkAbout15-192CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319)356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO. /S- I Q
(Office Use Only)
APPLICATION FOR TAXICAB / 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
3. Contact Information (REQUIRED) Email:
(All written comm
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
0Wn 0117 IA S LZLhb
a I' i 'Cell Phone: IS I el 3 ZI 1 L47 -7-
5.
-Y7 -Z
5. Prior experience in transportation of passengers: j , IcTi a ( 'i'", , 1 2_ !� 4e or k t,-
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Where
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? �''o✓"'
Type of offense Where When
Pc'c d -r(c l c IOct/ A(1 -r' ft
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What happened to the charge? (Circle one)
5<!I--- Tke ,(sack`' I t
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)
f V U Jnr..
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)
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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
ff r� r '�,?V issued on _� , t c, expiring on se, I understand that if I
falsely answer any questions in this appllCation, 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-�2FF " Date 02-3/- 1,
STATE OF IOWA }
COUNTY OF JOHNSON )
Subscribed and sworn to before me by W\D�g t glg_)tjo Li Y41 ti on this day of
A .. -i I t
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 t79
�� �_
Signature of Police Chi f 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.
Signa%Fe of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
!�/i // s
Date
Gle,k/TAXIDRIVBADGWPL92D14amended.DOC 0312015
C lomfa department of Transportation
AO Office. (A nrrvw `iiefvlces (TUI Five) 8WS12.1121
PO 1i. Dos 1 oii w 5030&9204 515-244,9124
F W 515-259-183 F
Certified Abstract of Driving Record
Inquiry Date:
8/31/2015
DL/ID #:
465AF7080 (LAI
Customer #:
5751120
Name:
Elamin, Mohamed
Class:
D
ID Status:
None
06/08/2012
Bakri Mohamed
Seed Johnson
IA
08/31/2013
04/30/2014
Address:
92D BENTON DR
Audit #:
7953132
DL Status:
VAL
Seed Johnson
IA
Issue Date:
04/04/2014
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
09/13/2017
CDL Cert Status:
None
522465216
Endorsements:
3
CDL Med Status:
None
Mailing Address:
920 BENTON DR
Restrictions:
NONE
Restriction
None
Supplement:
Date of Birth:
9/13/1962.
Mailing
IOWA CITY, IA
Sex:
h1
City/State:
522465216
History Information
Convictions
Citation Date
Conviction Date
ACD
Ex lanation
Count
JUR
11/20/2010
12/06/2010
_
N63
Driving Wrong Way Joh uson
on One Way Street.
IA
04/03/2012
06/08/2012
S92
Seed Johnson
IA
08/31/2013
04/30/2014
S92
_
Seed Johnson
IA
11/20/2013
04/30/2014
S92
Seed Johnson
IA
02/20/2015
03/27/2015
S92
Speed Johnson
TA
Name: Elamin, Mohamed Bakri Mohamed DL/ID: 465AF7080
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 DepnrGrient to be set upon this document, at Ankeny, Iowa
this date:
g.
19
2015 10:03AM
Div of Criminal Inv estlgati0n
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STATE (IF IOWA
Criminal History Record Check
Request Form
To: lOva Divlsiun of Criminal Invesgatinn
tympporf Operatlont Bureau, 1" Floor
215 E. 'I" .fitrcet
Eyes Moines, Iowa 40319
(515)'125-6066
(51spi"s-6on Par
1 am reaucrtinL, an lrnva ('rim;,,0 P,o-i A fll,rnL n,.
O(ll Account )Number: ' 1=
Qfappliceblc)
Prom:
City Clerl('a Office-----�-�-
410 C. %ishin ton 3lrect
Iowa Cil 1, IA 52240
Alrone; 319-356-5041
rac: 319-356-5497 ---� —J-- ---
Last Name (nlsndalory)
F'1Ys1 Name (nlandsl4ry)11
lddle Name (fecolnmendcd)
ZLa11, 1l
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Ge�de�Y (meneam y7
Social Securery Number (feeommtnaed)
DateofBirfb (marldalor)_)�
1— 3- �9� 2
L'JMale ❑Fealaie
2 J S-57 S S3 z
1 "aivC1' XftfOYMati01t: 1Vithout a signed waiver from the subject of the request, a complete criminal hisfory record may nol
he releasable, per Code of Iowa, Chapter 692.2. For templet e criminal histoy record information, as allowed by law, abvays
obtain a waiver signature from the subject of the req ucst
Waiver Release: 11mre0)' give pcnnhsion for Il¢ above requesting alfcial to conduct M lalva criminal Itislory record check *ilh the r)i),ision of Criminal
InY611ganell (tci). Any criiniml llisloly dmo wpicer11111E rile Ibal is ina11112mFd b)IIIC DC) may he relcmtdos Blokvtd bylaw.
lf�
]3/rtrver'
Towa Criminal History Record Check Results -- (DO Its. e„il)
As of �pp, �`�� a searcit of the provided name and dale of bit1h revealed -
No Iowa Criminlil ]]islnry Record 1`ouud )ailh DC) u;'lt
-:;
Iowa (:rinlinal ]listury Record attached, DC1 A i
C)
DC] initials___-_
UCJ-77 (09125/10)
°yTS-EVIL"[f i.'try
8/31/205
D fl. T
r)
LR�Yt
Office Driver Services
of
Iowa Department of Transporation
Name: Elarnin, Mohamed Bakri Mohamed DL/ID: 465AF7080