HomeMy WebLinkAbout15-204Al
a
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52 240-1 82 6
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) _[
IDENTIFICATION NO. l
(O se Only)
11; - IP t�l
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m- to 3 p.m„ Monday — Friday)
aiturfeto co .antpfefe the "re uiree information w,iFI restett in deniaB c f the apRiicatian
2. Address (REQUIRED) -�—�
3. Contact Information (REQUIRED) Email:
(All wri
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED
Middle ^ ` Last 5 . (1) v I
Aa} Cell Phone:
sent via email)
-0��1_��- 1/2n23
rs: u� l ) L ln,�O�M / uiC Ce ice. IIj a t l(7I.11
5. Prior experience in transportation of passengers: � � � � LiLi
q
T�1 �n1/AM �—/.1Nr �<.1
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested I charged with any traffic offenses in the last five years? A o
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other p
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 name(s)
r»
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT, --5-3-"
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE -HGF REVIEVu v
$#
You must apply for an individual Department of Criminal Investigation Report (form avattaW ugc�gn re t .
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTAWq, n
I
zr
"'- „ 02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I he�eb/ycqe.rtify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
�V LF 6 3 7 issued on OS/f3 f /expiring on $ 11 � / 23 . I understand that if I
falsely answer any questions in this application, that this appticatlbn may be denied. Il agree tthhat inn 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)
A
Signature of Applicant I Dale Z � 70 IS
STATE OF IOWA )
COUNTY OF JOHNSON 1
Subscribed and sworn to
aOIS
before me b 2�`� ''
Y IM(1 n� "14Llxll^-Q A-Sltiui, on this J!9 -
I ,
1,
NfENDV S.MAYER
ia�en-NurnW
My Com i5 lan Expires
bww
7-
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).
n
Expiration date of Chauffeur's licensec-
Signature of Polio f or designee
/2 )/-2
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.
Signature of City Clerk or designee
Date
C]KkfTMICRIV9ADGEAPPL92014amended.DOC 03/2015
Office Use Only `'
r�
C7-
0'
rO
f
Approved application
J
-°'
DCI report
State certified driving record�e
?;
r
Website update
co
C]KkfTMICRIV9ADGEAPPL92014amended.DOC 03/2015
3
p i• c!ii Iv•vJ'I'll vIu v vI Iill 111aI 1II v CJ l lb'µl VII
Frorv�:Clcy W Iowa Clly Clark Clelcc 319 3555aB-
R fJ4f0 r. 1/0
Ob/18120'fd 13:00 0212 P.002/002
STATE OF IOWA
Criminal 1-1xstll(,y C11(�ck
Rque;st Form
Tu: Iowa Division ol'Crimioal Inlrsfigxfion
Support Uperallons ifureau, I" floor
215 E. 7" Jtrcel
Dusft4oines,lOH'a 50319
(515)725.6066
(515) 72.5.6080 Far:
1 an -1 requesting an
e of mrth r ,.,n,......
DC;) Al Nioribc.r (U[)a =r
(ii applicable) _...
frrool: Cif� uflowa,Cty
410 ! . 4ashinglon 8'trecf
• fow•a Cify, fA 52240
Mile: 3I9-356.5041
Fax.: 319-356-5497""`---'---`-
114ED 1 0L)
Tilaiver L=fovwreOx; signed Waiver frmn the subject of the regoe 1, a complete svcord nrap nal
re
releasable, pecrimina� hismry
be relr Code of Iowa, Cbapter 692.2. For co_ mplEle criminal hlsiory record infill ns allowed re lard, always
Obtain a aiycrsi nalare from lhesub'ect of the request.
Walver Release: I hcrcb —
Inve S lavcpcnnissioa ry the ahOvp,41 s i Il ofilcial m eonducl an IOHa ttinthlal Lislory record check Wilh the Dir�lrion of CH iaal
sligelial (DCII. nnp trimillal hislory data cone<ming me Ihel is main�lain(e'J by the UCI rna5'bo released as allmved Oy law.
410h,er short alum.
As of
ulI revealeQ:
Nil henna Criminal M.S101Y Record found with DC:J 1
Cnrs
jorla Crilnhl9l Historl
Record altat:huf3,
DCC -71 (08/25/1(j)
DC] initials �.
c�
lt1Cl list only)
.,'WA
DDT
AU" I _tr'7PLH I CUS TOME I}IiIVEN
Office of Driver Services
FO P-3% 9204 ! Des Ntomes, IA 50.06-9204
Phone: 515-244-5124 t800-532 1121 1 Fa,,, : 515-.239-1937
www'i wad"A goo
Certified Abstract of Driving Record
Inquiry Date:
8/26/2015
DL/ID #:
450AF6378 (IA)
Customer #:
5729103
Name:
Sharif, Mohamed Ali
Class:
D
ID Status:
None
Address:
2413 SHADY GLEN CT
Audit #:
9336298
DL Status:
VAL
12/07/2013
01/22/2014
Issue Date:
08/13/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
08/17/2023
CDL Cert
None
522464115
Date:
Status:
Endorsements:
2
CDL Med
None
Status:
Mailing Address:
2413 SHADY GLEN CT
Restrictions:
NONE
Restriction
None
Date of Birth:
8/17/1978
Supplement:
Mailing City/State:
IOWA CIN, IA
Sex:
M
522464115
History Information
Convictions
Citation Crate
conviction Date
ACD
Explanation
County
3918
11/20/2010
02/15/2011
M14
Fail to Obey Traffic Sign/Signal
Johnson
IA
05/11/2012
08/14/2012
M70
Improper Passing
Johnson
IA
12/07/2013
01/22/2014
S92
Speed
Johnson
IA
Name: Sharif, Mohamed Ali DL/ID: 450AF6378
Pursuant to Iowa Code §321.10, 1, 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:
r-3
/l®`o'iFl11CLfp�` II 8/26/2015
Office of Driver
ces
Iowa Department eof'Trransportation
t _ �
Name: Sharif, Mohamed Ali DL/ID: 450AF6378 G`