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HomeMy WebLinkAbout15-214� Ali CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. (Office Use On )— APPLICATION FOR TAXICAB i 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 rst Middle Last 2. Address (REQUIRED) I MOSc S �L�r�tivr v� 3 Contact Information (REQUIRED) Email: � aSS1.,-, -e.la ,,,'ovr ,,r„cr;s\ -C "Cell Phone: ZcI -16 70 (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) - 1� 5 Prior experience in transportation of passengers: o)-'2- 6. 22_ 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense \� lJwx.7�;lef- Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arreste charged with any traffic offenses in the last five years? tJ b Type of offense What happened to the charge? (Circle one) 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 years? N J Type of offense Where When 9. Have you ever apAplried to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) 4v 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) 02/2015 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 :� 9G A-K� � 7 4, issued on ocl 19 11qexpiring on o(/ J 9 / 2-Z 1 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 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date O �t7Z S STATE OF IOWA ) COUNTY OF JOHNSON ) 1 l Subs ril ed an swom tp before me by jasso-v,—f yV)\I—CL on this �rG� day of / I _, TUTTLE i i KELLIE K. < y tarn' -i—tdumber 22181 n exolres ctary Public in and for the State of Iowa 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 Signallure o4lbolicChlef or designee or Irk 12022 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. �Cl Signa e of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update -7/s///-5- to Clerkl IDRWUADGEAPFL92014am ded.000 03/2015 State of Iowa Division of Criminal Investigation 215 E. 7'' Street Des Moines, Iowa 50319 Phone: 515/725-6066 Fax: 515/725-6080 Iowa Criminal History Record Check Walk -In Up"ii PQt Your name HA SSRN PTtfMG-D Address: ) 2 I I p -S oow� i° City/State/Zip JwLiS2e-i S Phone #: 01 z/) 2.c:75 - 6-7 c Requesting an Iowa criminal history record check on: Fill in all shaded areas. Last Name,41,eiwo(ma„djLorn) First Name Middle Name S8gvneb.N�ombr e(,ecoi,niena�) f3N H CD HASSRN -Gender�r�•ro moHAMED CLA-MI N Date of Birth rvarimrrnlo (mandnwrv) rmandatory) Social Security Number pccommcoded) lzMalc ❑Fema106�{-�(S-���© As of a name and date of birth check revealed: WaiverSi nature 0ui�e ,p�uee.fga irmerey,����snn��m,�,rtmc�sc,wr;a WA) - 47 �' Results LS[ OVCP r�I As of a name and date of birth check revealed: f 47 �' ,j �f l o record found N CO g,. _.. Tj o ❑ Record attached DCI it �= .t L DCl initials I r o -1 Receipt Number of requests x $15.00 per last name = Total amount $ )S"66 Method of payment: cash money order check # ILIWMasterCard or Visa Cardholder's name bkc�-,aS ah- p hM'p-Cc DCI initials W Credit Card # DCI -83 (09/09/ 10; Revised 10/ 1 / 10; form reviewed 08/ 11/ 14) Exp. Date C,m%jWi#Jl'A DOT re 7ANVV'1 C i vvad�7t, goV h+L SiFA, Office of Driver Services P---1 nax 9204 i Des Maines. IA W3v6-y-04 Fho-.e: 515-244-_1241800- 3 :21 i Fax: 515-239.tY37 wws.ro�€dot g9v Certified Abstract of Driving Record Inquiry Date: 9/3/2015 DL/ID #: 799AK5578 (IA) CDL Permit Class: None Customer #: 6213514 Class: D CDL Permit Issue None Date: Name: Ahmed, Hassan Mohamed Audit #: 7995578 CDL Permit None Elamin Expiration Date: Address: 1241 MOSES BLOOM LN Issue Date: 04/18/2014 CDL Permit None Endorsements: Expiration Date: 01/18/2022 CDL Permit None Restrictions: City/State: IOWA CITY, IA 522451590 Endorsements: 2 ID Status: None Mailing 1241 MOSES BLOOM LN Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing IOWA CITY, IA 522451590 Supplement: CDL Permit Status: ELG City/State: Date of Birth: 1/18/1978 CDL Cert Status: None Sex: M CDL Med Status: None History Information CLEAR DRIVING RECORD Name: Ahmed, Hassan Mohamed Elamin DL/ID: 799AK5578 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: -'•"'•'A/�4+ 9/3/201,x,{{5 10 WA %wt D. 0. T..;e�" 'Afli11E��°r Office of Driver Services nyIowa Department of Transportation Name: Ahmed, Hassan Mohamed Elamin DL/ID: 799AK5578