HomeMy WebLinkAbout15-213m'1[
CITY OF IOWA CITY
410 East Washington Strcct
yuwa CII Iowa 52240-1826
I—
(3 19) 356-5040
r X
IDENTIFICATION NO. 15
(Office Use Only)
APPLICATION FOR TAXICAB 1 MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 9 a.m. to 3 p.m, Monday - Friday)
railure to complete the "regahed" information will result in denial of the application
First Middle Last ,
1 Name (REQUIRED) 5' E pflfj _I MOHArAE0 rf-1-4
2. Address (REC)UIRED) �� Sra r-�X^ 12GSL{37 a WL; QttA (O
3, Contact Information (REQUIRED) Email: S}tihq-hec�+n(�heimu'Q-c�w Cell phone:(5 /1q)
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 10.;2 1.;2(51 q L
n ^C1 t C0.
b. Taxicab l3u5irless Name (REQUIRED) C 1tG ['Gt.�o Cirv,n PU ^ u� t X
5. Prior experience in transportation of passengers:-7::Oy,vte�C '76(jf-o, Ccr_ -let)c c ceA-J dktV-P-r
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies In this State or elsewhere? AR)
Type of offense Where When,, c ,
'a
Arm
What happened to the charge? (Circle one) .,
Convicted Dismissed Deferred Suspended PleadGuily Other
7. Have you been arrested I charged with any traffic offenses in the last five years?
Type of offense Where When
Ar 0
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 rani
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You mus'_ 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 hereby ce tify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
I � S"- � � � f 6 issued on D .2 - expiring on lb d I aoi 4 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, 1
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 f T140,,chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant- \jVAj Date C _ U Q O (S^
STATE OF IOWA
COUNTY OF JOHNSON ) %
Subic ibed a d sworn to before me by 1,6 �i Ila /�ttli /l / �! on this C day of
f i z�,, 5"
R`r, 6F_LIE K.
kkk**µµkµ###k*1****kktkkkk*ktk*
and for the State
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).
/z—
Signatureo e hief or designee
VZ -7,1115
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
f1� //,-5-
' Date
Office Use Only
APR 0 2015
Approved application
DCI report
State certified driving record
Website update
derv✓rfxiumv ADGEA"Lge'M,,u,,va Dee 0212015
Page 1 of 1
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WORTH 151 It°t._i. i CWTNVIE
Of ro of Drivd f Services'
PO Dox 0204 i Das 6r:cir,ea, la 50-06-92164
Phohe:?f5-244-9124 j 8011l f F2.e:`,1-t: /3'3-IE3i
'J{YF�k..IG1'i2�tJ:.gOK
Certified Abstract of Driving Record
Inquiry Date:
3/25/2015
DL/ID 4:
435AA6105 (IA)
Name:
Ali, 5hihabedin
Class:
D
CDL Mad
Mohamed
Status:
Address:
2540 BARTELT RD APT
Audit #:
8210397
1C
Issue Dale:
06/78/2014
City/State:
IOWA CrrY, IA
Expiration
10/23/2019
522462723
Date:
Endorsements:
3
Mailing Address:
2540 BARTELT RD APT
Restrictions:
NONE
1C
Date of Birth:
10/21/1961
Mailing City/State:
IOWA CITY, IA
Sex:
M
522462723
History Information
CLEAR DRIVING RECORD
Name: Ali, Shihabetlin Mohamed DL/ID: 43SAA6105
Customer 4: 3940416
ID Status: None
OL Status:
VAL
CDL Statu=_:
None
CDL Cert
None
Status:
CDL Mad
None
Status:
Restriction
None
Supplement:
Pursuant to Iowa Code §321.10, 1, Kim Snook, Director of Offlce 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 ar.thorized by the Director of the Iowa Department of
Transportatfon to so certify.
In witness whereof, I have caused my signature and the seal of the Deparment to be set upon this document, at Ankeny, Iowa
this date:
��rtE�Ctf y/ yr
i
9v; :k9
n`gMeo.
Name: All, Shihabedin Mohamed Dill 435AA6105
.3/25/2015
c1l 040l
Office of Driver Services
Iowa Department of Transportation
I
A
F
APR 0 2 2015
3/25/2015
Mar.27. 2015 2:35PM Diel o ('tirsinaI lavestigati)n 'h.3632 P. 8/0
f�ar.26. 1CI
015 12:34PM City er.4 - City of fo'iid Cit yNo, 5758 P. 2
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Iowa Div rAov of Criminni Yuv:,stigaiton
Sapp art Op eva(Ula Burtau, l'f Vioor
27M Tia $tre,:r
DolMoh:e9jona sj'aJ9
(Al -S)'725-6066
(515) 7266030 tial
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(iFeppllc hfe)
Y1'om: _CifyoflowaL'ity
Cify Clc'Ws C11iea
9X0 E. Washin too Street
Iotya Cit 1A $2240
Phone: 319156-5041
Fag: 319-356-5497
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1 am an .rolva Crinvaal Histol Reeodd Check on;
�$@E 1°lailRE (maudel0 jI'S(/t Name (aaandai� ]l�ll/f� dle Narno Wec mplmf lded)
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Q d �' A (, f q� I I omale ❑Feknalo I146 , 7(, —6�'S-6
l�aiverinfarmaLlanc Without a argned waiter from theaubjeer of [ho request, u couipleto crEmhial history record may not
be releasable, per Code of Iowa, Chupfer 692.2, ;For compiefs'vim lual histm-y record Informancn, 39 allowed by law, always
obta hi a Waiver sienature from the salbleet of the reaunt.
lfrfivrl'.tialefaee lkcrmby glvo pcnnfission Portheehoya reQmslingoffcdol m conductanTmva criminal hlslayfecundcheck\rilh the D1Nslaa aPCripllusl
fnvni igollon (D% Any erlminul hfelorydzis cmtniningMo 1tA04 Iafned by Mo ACl may bo actu d as alrowed by iatiu
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AV VT Ca v.r ARMS IL "M'AtlrV JnCC 7Y(t tL.EICCi MCSUZtg (1)cr uan oily)
As of .3 a a:earch aflfwpiovldedname and dato ofbirthrevealed:
240 Iowa Criminal THstoxy Record found wilh DCI
®%waCriminalHistoryRecordviMol-ed,DO#
M1 initials__
Received 7ime7Mar.20,2015 12;29PM Nlo.380C