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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52 240-1 82 6
(319) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED;
IDENTIFICATION NO
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICA13 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
3. Contact Information (REQUIRED) Email: �ha%7nc %2� rn `aA , c t Cell Phone wt % 1
(All written communication sent via email)
4a. Chauffeur's License expiration date (R
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of
pa„�iiycib.
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? /,Jo—
Type of offense Where
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended
Plead Guilty
Have you been arrested / charged with any traffic offenses in the last five years?
Other
vvnere
tZ When -pled, qut ftl
ll Tn�lan rr �d,o I` II!
AI I II 1 I r+ Q t .Z � ri�y9sler�
A�tris �dAt�4ert L t I I�I14 � H
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 o
L3 cn
9. Have you ever applied to be an Iowa City taxi driver using a different name?If yes, please provert�he nCme(s)�
/V0
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CI=RTIFlffg
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVft
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 e fy thatI have issued to me by the Iowa Department of Transportation v lid Chauffeur's license number
issued on o a 7 m1 'expiring on o (1 '? c ( 1 understand that if I
f sely 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 applicati n, and I further agree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions OYI r, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant �) Date og c L %ls
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me by P\. M
�.o r
in and for
on this 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 (7q Ili 12b 1 iA
Signatur o Po ice Chief or designee
(70 127 (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.
Signat re of City Clerk or designee
ate
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Office Use Only
Approved application
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DCI report
State certified driving record
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Website update
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CleMrl IDRIVBADGEAPPL92014a..nded.DOC
03/2015
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wnwio dot.0v
Office of Driver Services
PO Boa 9204; Des frlotues. IA 50306-5204
Phone_ 515-2 44 9124 18,00-532-4921 f fax.:515-230-1837
www Jowadot gov
Inquiry Date: 8/4/2015
Name: Mohammed, Ahmed Musa
Address: 1147 WINCHESTER LN
City/State: NORTH LIBERTY, IA
523179162
Mailing Address: 1147 WINCHESTER LN
Mailing City/State: NORTH LIBERTY, IA
523179162
Convictions
Certified Abstract of Driving Record
DL/ID A:
519AG3626 (IA)
Class:
D
Audit #:
9229982
Issue Date:
07/07/2015
Expiration Date:
09/11/2016
Endorsements:
3
Restrictions:
Commercial Learner Permit,
DL Status:
CDL Intrastate Only
Date of Birth:
9/11/1966
Sex:
M
History Information
Customer #:
5827626
ID Status:
None
DL Status:
VAL
CDL Status:
VAL
CDL Cert Status:
Non -Excepted Intrastate
CDL Med Status: None
Restriction CDL Instruction Permit
Supplement: Expires 1/7/2016
CK-t;oil Date....
conviction Date
ACD
Explanation -_�
count",
3UR
11/05/2011
.11/30/2011
S92
(Speed
John=on
IA
11/09/2014
03/18/2015
M14
Fail to Obey Traffic Sign/Signal
Johnson
7A
11/09/2014
03/18/2015
E55
.Driving Without Headlamps or With Park Lamps
Johnson
IA
Name: Mohammed, Ahmed Musa DL/ID: 519AG3626
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:
Pte"••"•"v •'p
8/4/2015
'IOWA m%
9�
Office
A711YER 5��
of Driver Services
�....:1Z„_
Iowa Department of Transportation
Name: Mohammed, Ahmed Musa DL/ID: 519AG3626
-9 07/28/2016 2015 9�05RM�lart0iv of Crimi al Investigation 07;26,2016 16:N(,1889H7 P - 2/002
STATE OF IOWA
Criminal Hltory Record Check
y' Request ForllI
'fn: Iowa IMUion of Crindhal lnvestigatiuu
Support Operations Bureau, I" F10011
215 L. 7" Street
Iles Mninessluwa 50319
(:15)'125-6066
(Ci15)725.6080 [>as
Tam requeshh>; an Iowa C
T ast iwalm a (mandaloq)
Date of Birth (,nandalary)
Oa lel I (� 66
Check
f,A k cj
DO Account number:-.-_--
Lifapplitnalc)
Frmn: - CltyoFfowa CESS _ _____ --
City Clerk's Office _
410 C, Washington 81reeL
lou'a Clly, JA 52240
phone; 319.356-5041
Foy: 319556-5497
Eh le ❑Female
So
UO3a
e
W(river biforwatiori without a signed waiver from the subject of the request, a complete clitninal history record may not
be releasable, per Code of Iowa, Chapter 692,2. For complet nitninal history record information, as allowed b1� law, ,,vans
obtailt a waiver slanabire tram rhe e,.l%4 .ot nr rhn ran..o�e
Waiver.iletease: I herthy give permission for b vc req%pSsliag ofpoial m eonJucr an lova Criminal history record check Wilh the Division ofCominot
luvuligalion (DCq. Any criminal hislol •data canan) . gT a tial is @pialyined'b,, Iht DC( may bC released es allowed by tan.
IT'aivel"S'Orattu'e�. l "\\. , , -h . , -C a A
Iowa Criminal History Record Check Results I Oci we oulyJ
As of -2� a .search of the provided name and dale of birth revealed:
c?
No Iowa Criminal tjisuny 12ecprd lbund v;ilh I)(:1
❑ Iowa Crinllnal Nisturs, Rceord allached, 1)CI 11 = ''
DCl
DC1•77 (09125/10)
Received Time )u1.26. 2015 2;20PM No.IV3