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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)
3. Contact Information (RE
IDENTIFICATION NO. 15-1 a
(Office Use Only)
APPLICATION FOR TAXICAB l MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
Failure fa carni Tete the "reorrireef" information will result h? denial of the application
Last"
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4a. Chauffeur's License expiration date (REQUIRED) O
b. Taxicab Business Name (REQUIRED) f/f if CL✓
5. Prior experience in transportation of passengers:
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6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
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)
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATr:zCERT,ED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE;F REVIENL
may;.:
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You must apply for an individual Department of Criminal Investigation Report (form avattafAb upgn remt).
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(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARYII"-
K` ' 02/2015
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? IV/0
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)
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATr:zCERT,ED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE;F REVIENL
may;.:
c 7-4
c i
You must apply for an individual Department of Criminal Investigation Report (form avattafAb upgn remt).
=it, J 3
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARYII"-
K` ' 02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereb� certify that I have issued to me by the Iowa Department of Transportation, a valid Chauffeur's license number
l) �E 6 Z �q issued on pRji�expiring on Lia . I understand that if I
false answer any questions in this application, that this app icati n 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 �f� �' Date Zb 20��
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to
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before me by Poal tA..e )L�D A . S L lG f _�::L on this a S� 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 (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license L' ') ?
Signature of Poli c 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.
Signature of City Clerk or designee
Date
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Office Use Only
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Approved application
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DCI report
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State certified driving record
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Website update
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cies✓rwaoarven GEAPPr92014am.1ded.Doc 0312015
Aug,19, 201'1 10:03AM U i v of Criminal tnvest12atIon
Fro [rt Gl[y pi IDWS Clly CI orK Offlcc 319 3666487
06/161201C 13:06
STATE OFJOWA
Criminal Historl l Record cllerfc
Bequest Form
TU: Iowa Division W Criminal Inresf iga(ion
�0pp0rI Ojxrauons lhtreau, 1 i1 rtool-
3.15 E. 7" Street
Das MOinc-410ma 50319
(515) 725-606(,
(515)U5-(1080 rax
Y, V 0
4212 P-0021002
L}(;1 Accnwtl Numhea: __-'IUQd _I: _
(ir ayplitahle)
....---
City C1er11's QrricO
410 E.'4Vashingi0n Street
]uwa Cify1 lA $2240
Mile: 319-356.5041
Fax: 319-356-5497---`---
C1DOT
SkIlPtUP I Si PLIr I EU`�TUfi�'EtF DRIVEN J1�,SpVV �i{��,i Ql�
Office of Driver Services
PO Box 92041 Des PJioir>es, CA 503&3-63G4
P'honc 515-244-9124 1806-532-1121 I Fac 51151-139-1837
wwwJw.adot gov
Certified Abstract of Driving Record
Inquiry Date:
8/26/2015
DL/ID #:
450AF6378 (IA)
Customer #:
5729103
Name:
Sharif, Mohamed Ali
Class:
D
ID Status:
None
Address:
2413 SHADY GLEN CT
Audit #:
9336298
DL Status:
VAL
12/07/2013
01/22/2014
Issue Date:
08/13/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
08/17/2023
CDL Cert
None
522464115
Date:
Status:
Endorsements: 2
CDL Med
None
Status:
Mailing Address;
2413 SHADY GLEN CT
Restrictions:
NONE
Restriction
None
Date of Birth:
8/17/1978
Supplement:
Mailing City/State:
IOWA CITY, IA
Sex:
M
522464115
History Information
Convictions
Citation Date
Conviction Date
fcCD
Explanation
County
]UR
11/20/2010
02/15/2011
M14
Fail to Obey Traffic Sign/Signal
Johnson
IA
05/11/2012
08/14/2012
-M70
Improper Passing
Johnson
]A
12/07/2013
01/22/2014
'.S92
'Speed
Johnson
]A
Name: Sharif, Mohamed Ali DL/ID: 450AF6378
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:
ti QE..... , 8/26/2015 C
r:
IOWA`�s°
y ; D. 0.
Office
Departme Serf liTransportation--es
Iowa � g
?!
Name: Sharif, Mohamed Ali DL/ID: 450AF6378 C.]