HomeMy WebLinkAbout15-212!rIIIMlsIc ;z
CITY OF IOWA CITY
410 East Washington Slrcct
Iowa City, lova 52290-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO. _� atai
(Off',,., ..e unly)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
Faffure fo canlpdeie fhe "required" informa€iorr v,:ilf resuff In dental of the applicdtian
First
/ $,3 7
3. Contact Information (REQUIRED) Email: �5+ryt
Ile
(All written communication sent 9 email)
Cell Phone('? I9) 4?1
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) �e
5. Prior experience in transportation of passengers rry tIt i vel - �FGLy r 4, —j i/"
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? 00
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
Where
When
Other
03
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 c
cb
9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please IA the
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATI'LtERTIhhl]
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF RVIEW
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 hereby_certify that I have issued to me by the Iowa De rt ent of Transportation a vali Chauffeur's license number
71 Z $ 3 2issued on o 2° / expiring on o ] o of I understand that if I
falsely answer any questions in this application, that this appli tion may be denied. I ogre 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, CC ter 2`of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant
STATE OF IOWA )
COUNTY OF JOHNSON 1
Subscribed and sworn to before me by Taj un, !'DLLQ M p on this _�qday of
�_ 301.
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfI have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
dents of the City of Iowa City (Title 5, Chapter 2, City Code). are of resi-
Expiration date of Chauffeur's license
�21
Signature of Police h), esi' gnee Date
AFTER APPROVAL THE CITY CLERK YOU ARE AUTHORIZED
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. TO DRIVE A TAXICAB IN IOWA CITY FOR NO
ZjlgnatLn,e of City Clerk or designee
/ / /
Dafte
ClerW TA%IDRIVBADGEAPPr92014.me,ded.DOC
0312015
Office Use Only
i r *
rV
Approved applicationI"—
°
DCI report
{"
3'
State certified driving record
Website update
r
ClerW TA%IDRIVBADGEAPPr92014.me,ded.DOC
0312015
VVVjW.iow dctgov
SMARTER I SI?i#FI_cF I CUST(MN, DRIVEN' N, v . W _ A I — - -
Offlce of Driver Services
PO Bos 9204 . Des FLnwes, to 5030e,-5204
Fhore: "15-244-9124 1800-532-1121 1 Tar,. 51 5-239-1237
t4^N'd. '-duan got
Inquiry Date: 8/19/2015
Name: Mohamed eakheit, Ismail
Address: 1837 GRYN DR
City/State: IOWA CITY, IA 522464406
Mailing Address: 1837 GRYN DR
Mailing City/State: IOWA CITY, IA 522464406
Convictions
Certified Abstract of Driving Record
DL/ID #:
775ZZ6832 (1A)
Customer #:
3874967
Class:
D
ID Status:
None
Audit #:
8317464
DL Status:
VAL
Issue Date:
08/02/2014
CDL Status:
None
Expiration Date:
07/04/2019
CDL Cert Status:
None
Endorsements:
3
CDL Med Status:
None
Restrictions:
NONE
Restriction
None
Date of Birth:
7/4/1959
Supplement:
Sex:
M
History Information
Citation Date Conviction Date ACD Explanation County JUP.
09/08/2013 03/27/2014 N82 Improper Backing lohnson IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Ac6dent Date Case Number IUR
09/08/2013 --756111 ,JA
11/22/2014 :830163 IA
Name: Mohamed Bakheit, Ismail DL/ID: 775ZZ6832
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:
% ��®Q� ••..••• :v/p4�r
B/19/2015
IOWA `s
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Iowa Departme Department
Name: Mohamed Bakheit, Ismail DL/ID: 775ZZ6832
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STATE OF IOWA
Cr[1ni12al J`j1s(t)ry RCeored .'Fleelt
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RegUe:st Vom'i
TO: tnwn Uivisiun got (,I-imonal Ima�Sllgatiun
4uppurt OperationsFFrun-
215 L 7", street
1)es ),Moines, lova 511319
(SIS) 725-6066
(515) 725-6080 I ax
- -• __ rsrst name (menet
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r)CI Accnunl
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Froeu _CiLy_oflowa
C:ify Clcrh's Office
001. Washin tonS(reet
lova Cily, LA 52240
Pbone: 319-356.5047 ry
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n-uiver inJOI'Matiofl. AI(how a signed waiverlro� hi The subject of the r L a complete criminal h` is(ory record may not
be releasable, per Code of )owa, Chapter 492.2. For comnlcte criminal history record information, as allowed by law, ahvays
obtain n waiver signature from the sub act of the re ucsL.
1i�aiver Release:u�ereo ;�r � --�
Imesdgatlon (DC7), pn q; y pEonission for Iqe above rtgpeslipg ORmiel to cooducl on lows criminal hislOryreoord q¢ek wi10 WE p1%.isien o(Crlmiirsl
> mitral history dela conntming me Ilett is maintained 6yihe DCI may 6E weaned es 1110vcd by law,
14l(fiver Signature:
As of U �^ a search Of the provided name and date of bill), revealetl
A'o 10Wa C9rninal 1- MOry Record found with 1)C:1
lova Criminal l-lislury Iteca,d attached, DC'1 N,
DCI initials r V 1
I)CI-77 (OS/2S/10)
Received Time Aug, 19. 2015 4'D4PM No.3559
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