HomeMy WebLinkAbout15-218j IDENTIFICATION NO. J .r7 -12/V
s (Office Use Only)
CITY OF IOWA CITY
910 East Washington Strcct
jowa
City, Iowa .52240-1826
(317) 356-5040
X
pfd -d4(-(
Ar r -4 r 111N WK TAx1 AR r UQTQR�-DICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
Failure to eofnplOtO fhc "reuuired" information will resali in deniai of fhe app/lcation
First Middle ! ast
I. Name (REQUIRED) �F 1 K)L A rA I 0
2 Address (REQUIRED) 2-5-qD IS— a6tir4m 01fi+q `,A 3 2-2-JA(0
3, Contact Information (REQUIRED) Email: Cell Phone: Iq) qCD
(All written communication sent via email)
4a. Chauffeur's License expirationd-ate (REQUIRED) lt3.o2l.�61 1 _
h Taxicab BusiriessName iRECIJIRED)_ Cth) Cod, CrvtnPU^iA n IBX l CaL
J
6. Prior experience in hansportaiion of passengem -T�- Ir mvy� :Z66.rp; c1r" KCCckL p(fr u.p.i
6. Have you ever been arrested /charged with any misdemeanors and/or felonies in this State or elsewhere? N o
Type of offense
What happened to the charge? (Circle one)
Where
Convicted Dismissed Deferred Suspended Plead Guilty
7. Have you been arrested/ charged with any traffic offenses in the last five years?
Type of offense
AV
What happened to the charge? (Circle one)
When..
Ocher
Where When
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 yeais9 __
Type of offense
Where
When
201
9. Have you ever applied to be an Iowa City taxi d� Iver using a different name? If yes, please provide the name(s)
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)
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I herebyc rtify that have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
-i 5 7 x l I tit S issued on D(&.2_ - expiring on )Lr d I. doi 4 I understand that if I
falsely answer any questions io this application, that this application may be denied I agree that in making this application,
consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examine any and all records and
dccurrierls relating to this application, and I further agree that, if authorization to be a taxicab driver is granted, to comply Mall
t-mes with all of the provisions f Title ,1)Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date Q – 00 p 1 S�
- r
STATE OF IOWA J
COUNTY OF JOHNSON )
Sub,�ibed aid sworn to before me by /?, lira ham' -e /l /`] �/ on this day of
ff /
rxut flE K . TUTTLE /
.r otary Pubic in and for the State of Iowa
y' 9 Expires
iii*i#A***ki*iif.MYi4i:t*x4i}R4RYix*}kik##f}}Rk R4 *** HFf4#*i#k*k4**!*}A#}***f*44#kfk#**4};!*4#4f-l4:tR RR*i4RR#*R#R*4R#kRRR**iR*#*#*RRR*##*RR*
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the issuance would be detrimental to the safety, health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
/C
Signature o hiefordesignee Da
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.
THE EFFECTIVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION IF LESS THAN A YEAR.
Signature of City Clerk or designee
Office Use Only
— 7 Date
APR 02 2015
Approved application
DCI report
State certified driving record
Website update
Gle AXIDRIVBADGEWi_92014,,,M,.x ooc 02;2015
Page 1 of ]
DOT
SI}1rtRtER I s,t vL: i ft'T01 E>` f) 5 1 i.T?.�..�..�..�.�
�OVicte of Driver jServices:
PO Box 92c04 i Dai Moines, IA SD -1,06- 224
Phone: IS -244-9124 1 =:00 532-1121 1 F,7.t': 51 33E-1237
wwwJo eoda'..9ar
Certified Abstract of Driving Record
Inquiry Date:
3/25/2015
DL/ID 4:
435AA6105 (IA)
Customer #:
3940416
Name:
Ali, Shihahedin
Class:
D
ID Status:
None
Mohamed
Address:
2540 6ARTELT RD APT
Audit 4:
8210397
DL Status:
VAL
1C
Issue Date:
06/28/2014
CDL Status:
None
City/State:
IOWA CITY, ]A
Expiration
1012112019
CDL Cert
None
522462723
Date:
Status:
Endorsements:
3
COL Med
None
Status;
Mailing Address:
2540 SARTELT RD APT
Restrictions:
NONE
Restriction
None
SC
Date of Birth:
10/21/1961
Supplement;
Mailing City/State:
IOWA CITY, IA
Sex:
M
522462723
History Information
CLEAR DRIVING RECORD
Name: Ali, Shihabedin Mohamed DL/ID; 43SAA6105
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of I ransportatlon, 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:
w
3/25/2015
60'x:` . •so
��D.O.T.•��
Office of Driver Services
�'n OBIYEe €
�..n� Iowa Department of Tm nsportation Y"'
Name: All, Shihabedin Mohamed DL/ID: 435AA6105 OR 0 2 2015
3/25/2015
Ula r.
27.
2015
2:35PV
Div of Criminal
In vestigallan
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Supp ortfDpeca(Ions13ureau,I"Bioor
21511, 71e Sheet
kiea Moines, Towa 50519
(515) 926-16066
(516)735.6000 Sal
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Cily Clerleas Qfllee
AI0 E. Washhtelon SCreet
$owa C'!t !ti 52200
Phone: 319-355.5091
Few, 319-356-5497
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GYalverinformatiou; Without a srgned waiver from theaubjettof the request, a completo crfmival hlslory record may nut
be releasable, per Code of Iowa, Chapter 692.2, For complefs crlrohial hialai y record 1pfm maBon, as allowed by law, always
WhivarReleaSe. 1 kombyglvo pcnnission rorthaabove raqusstingotficla w condactm rove c1humal hlst ry record check\dlh theDiWslvn oPCiOnM?aal
fnru(i9e001l(DrD. Any Yrindnel hlslory data cogwaingtne lAatls (Mined bylhoACf may Dereleastd as al06wtd hylar;.
Waiver,Wgnature:
o va Criminal History Re ordE Check Resaftg cDclwooniY
As of .3 1 � s—asearch of the paocddedname and dato ofbirthrevealed:
140 Iowa Criminal 141tosyRecord foandwith DCl
® low& Criminal History Recardattaahed,DCI#
DClinirials.
Received Time7Mar,26.12:29PM No. 3800