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CITY OF IOWA CITY
410 Last Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1 Name (REQUIRED) -
IDENTIFICATION NO. /_`i— 1'P) 1.
(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)
rafPuLe Yo e orraple —the r_esulf in denial ofYhe appfiration
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Last
2. Address (REQUIRED) % 7��i ih _n( r, F ✓� ( T�l, l j khe q. CiZyy 6
3. Contact Information (REQUIRED) Email: `r'l�Z—'��,f��(1 }vn�;j r�Crell—Ph7on=e:'?=J1'-321-06�/�(
(Allavn written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 0 p
b. Taxicab Business Name (REQUIRED) o rl Cz✓t lM awt 'j(,6 CAj,
5. Prior experience in transportation of passengers:
O 'yu l4M -1—Ax 1 a
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
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? /V U
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? ft 0
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 STAT CERT' -.)ED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICEF BfcVIEVV.
-IEra
You must apply for an individual Department of Criminal Investigation Reporl
rt (form avaflab urn re"9t).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTAR.
_..._,N_. '• �.' 02%2015
y
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
0 (1 f F �� issued on��expiring on "7 L I understand that if I
false y 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 Date Z 61 2c IS
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by `1/�Z uA-2 eY i� . S 1tu f 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 orwelfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license C� /(/�-2 25
Signature of Police -M& or designee
i
Date
AFTERAPPROVAL 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
Approved application
DCI report
State certified driving record
Website update
F/ a' 7 //S
' Date
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Cler ffA%IDRNBADGEAPPL92014amended DOC 03/2015
-,
Cler ffA%IDRNBADGEAPPL92014amended DOC 03/2015
Aug192015 10:00JAiM Div u' Criminal X10,3416 P. P/b
, Fra M:Cl[y Ol IleWS Clry Clerk ufilcc 31'3 3686497
0b/18/201e 13:06
STATE OF iONVA
Criminal History R(;E id (711('.(;i{
r�egtwst Form
'I'u: Iowa Division nl Criminal Invesliga{ion
Support CJpero(Ions bureau, l" Floor
215 F, 7" Streel
lies (t4nines, Iowa 50319
(515) 725 -cm,
(5I5) 775.6080 Fax
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City Clevl('s OTricC .
410 L.'lN: 9shinglon 5'tneE
IUt'+a Cil}j JA .42240 -- �—�
Fbone: 319-356.5041
Fax: 319-356-5497 L'----`--
01-1
,IapMale QFemale 6 qr — g G r U Cj
IT/ad ver I1SfOf•mlffiDn; Without signed waiver from the subject of ltTc re r)uesl, a complete a•im incl history record may ndI
be releasable, per Code of Tows, Chapter 692.2. For emnplete criminal history record in€ormahion, ns allowed by law, sways
obtain a %atVcr si na(uro from the subicet of the reauesk
PINver Re16p5E: I hereby give pclnTission for The above requcmin@,official m 40"Juel an I'lla 011501 hislofyremrd cheek tvilh the pivision Of Crituillel
LIIMIIgeli[nt (DCII. Any I,imipaI history data wnccn)iog me Ihsl is rnainlaiaad bylhe DCI maybe released a5 allowed GYlaw.
------'^— Waiver S'iennfure: ,.�---�-` ---�'---'--- --�
Iowa Criminal Histor ' Record Cheek Result �---
mol Ilse oast
As Ofsearch Of lite provided name and dale of biflh reveale(i:,
ks: ryl i
Nii to le Criminal HiMM), Record round with DCl
❑ Iowa Climinal 14isun7Itecord atlaohed, llCJ tl_
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riff ice of Dover services
PO Box. 920-0'. Des fdlolnE4, 1.4 SU306-9204
Phone: 515-244-41241800532-11211 Fax: 515-239-1837
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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:
R
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 Elate
Convictiun Date
ACD
Explanztion
County
3=.tR
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
IA
12/07/2013
01/22/2014
S92
..Speed
Johnson
IA
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:
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IOWA
8/26/2015 C -
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of Driver S
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Iowa ion
Name: Sharif, Mohamed Ali DL/ID: 450AF6378
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