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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 PAX
1. Name (REQUIRED) t
IDENTIFICATION NO. )5—,211
(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
First
Middle
2. Address (REQUIRED) a4;yq f/� � v jou �f /« r l ✓ 5 5-2 2 -446
3. Contact Information (REQUIRED) Email:%thi94SS11V i Z,4py;� Cb>n Cell Phone: �%� �Oa st
(All iw� munication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) j�.�l Z; , 96&
It. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers: S
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? 410
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? YC -V
Type of offense Where When
/
What happened to the charge? (Circle one)
onvicte 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? AJ, -5
r
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 nffibe(s) �O
v -I
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE C IFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHPEVRW
M -0 gT;
You must apply for an individual Department of Criminal Investigation Report (form availatf10 pon-ieques"
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby cedify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
?j2 ,7; 6 issued or 9,. J. J_' _expiring on /o.er. ZS _ 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 , hapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date % /0. /,
STATE OF IOWA )
COUNTY OF JOHNSON )
S;u scribed and sworn to before me by J nA ii Y • NIyL%-QY)lxd l this / c::> 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 _I I ZatS/2s71 p
Signature of a ief or designee
4q/16/z,01-:5
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.
7%ler zc-� ,c.i—)
Sig ature of City Clerk or designee
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to
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Office Use Only
Approved application
DCI report
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State certified driving record
Website update
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Clerk/iAXIDRIVBADGF PPL92o74an,ended.DOC 03/2015
Jep. i. 2111h 3:31YM piv of Criminal 1nvestifaticn No, 4969 P. 2�5
F+�.... r.,, .. _. �.._ ._ , Clcrl. _....__ �,_ .,.,...._e, 00 /02/2076 1A:S � n2•]6 .--v�1/002
* j Criminal I'jisf0t-y/ R('COrf� Check
y ktquesf Fonio
luu•a DIVf.10n or C;r;alinal lnvesltga0bil
fiapport Operotiuns Bureau, 1'I Plow,215 P. 7'a $trcel
Dc's Moines, 1011-2 i'0319
(STS) 725-6066
(515) 925-6050 Fax
DCI AcCuun( Number:r'!vG
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City C'lerh'g-(]rfrde
410 11.'Wa., I loa Street
-Iowa C;ly, IA 52240
Phone: 319.356-5041 M1
Fair; --
1 am rc ueslinan lows Criminal Histol Record Check on:
]east Name poandnlnry) .Firs( Name �— ^~�--- —•--
(mandmory) Mid
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Mohtz,,)vl1da/,' L nay �Guelryrisi�i
Date of BirPL pnendaiory) Gender (manaalup)
Social .SEt:L111 ' 1\latnhei (mWmmendn
11 • ) 5' I?65 Gale ❑Female 7C5 — � 1— 3 $8�
Wpiver "zfOrlt10[i0I'- Without a signed waver from the subject olthe request, a complete criminal history record may not
be releasable, per Code Of Iowa, Chapter 692.2,. For ca. maleic criminal history record information, as allowed bylaw, alnays
obtain a waiverst acture from tfie subject of the rcyucst.
Waiver Releaser I heecb h'e ~
I nvetliaati on ) J riminal hi,l ryda I a'wn Ocming mG lhCQ1listing ofneial to wnducl an lolva ai,ninal lIWCIYreeord encck wllh lhelJiv{sion ul Crimieal
(DCI . M c enitalned by rhe DCI may bt released as all�ow,e\dd by In,
Waiver- Signalure
As
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—__, a search of the provided nanlc and date of I)it1h repealed:
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No Iowa Criminal Ilistnr '
} ReCtJI'd 1plllld Wlllt �C_:1
lilwa C;rjmi»nl Hislnry )tecord atlached, M..) Ii
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Received Time Sep, 2, 2015 2:25PM No,4602
C41UVVIADGTllnF EJ' I tJSr()MF: E�;�=vrs %Aj\/{L�r.t lti+c3 G . i)J
Inquiry
9/2/2015
Date:
522464115
Customer
6245436
Birth:
Name:
Mohammedali, Luay
CDL Permit
Abuelgasim Yagoub
Address:
2449 SHADY GLEN CT
City/State:
IOWA CITY, IA
Issue Date:
522464115
Mailing
2449 SHADY GLEN CT
Address:
,..
�Of.F.YIC(f ;'N"III
Mailing
IOWA CITY, IA
City/State:
522464115
Date of
11/25/1965
Birth:
Sex:
M
Convictions
Officr_ of Driver Services
FO Eos 9204, Des fto nes, IA 50306-92G4
Phone. 595--244-91241800-5.32-1121 IFa,<:51 5-22�9-1837
Aww iowado9 ao•
Certified Abstract of Driving Record
DL/ID #: 828AK0862 (IA) CDL Permit Class: None
Class:
D
CDL Permit Issue
None
�^
Date:
Audit #:
9387262
CDL Permit
None
Expiration Date:
1
Issue Date:
09/01/2015
CDL Permit
None
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Endorsements:
y
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Expiration
11/25/2016
CDL Permit
None
Date:
s
Restrictions:
� • IOWA �'��
Endorsements:
3
ID Status:
None
Restrictions:
NONE
DL Status:
VAL
Restriction
None
CDL Status:
None
Supplement:
CDL Permit
ELG
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Status:
•••••' $�`
Office of Driver Services
CDL Cert Status:
None
4y"BBIYtt�,=
Iowa Department of Transportation
CDL Med Status:
None
History Information
Citctlon Date Conviction Date ACD Explanation County 3bR
06/21/2015 06/26/2015 S92 Speed Johnson IA
Name: Mohammedali, Luay Abuelgasim Yagoub DL/ID: 82SAK0862
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 1 have been authorized by the Director of the Iowa Department of
Transportation to so certify.
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In witness whereof, I have caused my signature and the seal of the Department to be set upon this documeri Ankeny, Iowa
this date:
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Office of Driver Services
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Iowa Department of Transportation