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Home My WebLink About15-133l IDENTIFICATION NO. _ 1 _ 1 (Office Use Only) —r — APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) 410 East Washinglon Street Iowa City, Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (319) 356-5040 (3 19) 356-5497 FAX First{t. Middle Last 1 1. Name (REQUIRED) rttaS% AI Il C 65 61�a%Y5 ('SACCI.,, 0 in0 t 1 n FJ 2. Address (REQUIRED)i 6z��3n F sQ 3. Contact Information (REQUIRED) Email: C}S (ICC IZ 2oo�cj r\ync ,'� �,, _ Cell Phone: L 1 r� S 7cI (All written communicatio sent via email) (01 a 4a Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) )11� 5. Prior experience in transportation of passengers: �. yy0:1 Ck 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? IV 0 _ 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? p f ; Type of offense Where When 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? y,zi2 Type of offense Where When ti c q c., 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please p (e thesameL&) l� A t <= n DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATS RTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE�F R�VIE You must apply for an individual Department of Criminal Investigation Report (form avAble up n request). 4a (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby An n that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number h �� o Q?_ issued on � expiring on A/0 k I 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, I consent to allow agents or employees of the City of lova 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, C apter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date 06/' i q � STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by i )b /k D. lnbinnu � on this 9-r,�lA _ day of 7u w4 20)� n _ . e in a(iff for the State of I 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). license or designee 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. �)vI k . � Signature of City Clerk or designee to CleddrAXIDRN6ADGEAPPL92074amended.Doc 0312015 Office Use Only 4 c =tt'7 Approved application DCI report State certified driving record G z, x Website update ZE:= w �v CleddrAXIDRN6ADGEAPPL92074amended.Doc 0312015 Jon 4. 2015,11:26AMC ,Div of Criminal Investigation 06,0212016 ,e:eNc• 9695,10 7P. 1/1./002 STATE OF IOWA Cyiminal Higtory. t: Check Request Forin $3_ To: iewa Division of Criminal Invesligation Support Operations Bureau, 1'r Floor 215 C. 7" Street Des Moines, Iowa 50319 (515) 725-6066 (515)725-6080 Fax I am reouestinn an Iowa Criminal Idisfnry Record Check oat DCI Recount Number: (if applicable) Giron: _ Cify of Iowa City City Clerk's Office 410 E. Washington on Street Iowa City, 1A 52240 Pboue: 319-356-5041 Fa X: 319-356-5497 Last Name (mendator. First Name (mandatory) 11��7}}iddle Nance (rrremnreoded) �U/ILIWIWI _ �r�Si2 !e17 U�r10.t1 �5�. Date of Birth (mandatary) Gender (mandatory) Social Security Nuplber (ceconunwded) 001f °l% Iqgd _ �11'lalr; ❑Feutale 0e(q-5 eq�K Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692-2, For coy tete criminal history record inforntatian, as allowed by law, always obtain a weivel' signature from the subject of the request. Waiver Release: 1 hemby give per nissim for The above requesting official To conduct a lova criain,il history record check .vith the Division of Criminal lnvesmsation (DCO. evoo criminal history dam concerning n,e that Is awntai and by the DCI may he released as alloyed by lass. Waiver Signature: lawal Criminal History Record Check Results (DOmt Only) As of a search of the provided name and date of birth revealed: �,to No Iowa Criminal I-Iistory Recoad found with DCI T 'ern Q IaNva Criminal History Record altaclled, DCI tt w � rS -- r Iv DCt iliilials_ —J DCI -77 (03/25110) Received Time Jun, 2. 2015 4 NPM No -8499 .4W DCCT h AR74 i !N , I. P I ti.JSTO"A"R Office of Driver Services. PO Box 3204 3 Des Mabnes, IA M3GC3204 Phone: 515-244-9124 18CCY5324 1211 fa _ 51 239-1837 www iowadot.gov Certified Abstract of Driving Record Inquiry Date: 6/2/2015 DL/ID #: 582AH0582 (IA) Name: Mohammed, Nasr Class: D CDL Med Aldden Osman Oshar Status: IA Address: 2401 BARTELT RD APT Audit #: 8142283 213 Issue Date: 06/06/2014 City/State: IOWA CITY, IA Expiration 01/01/2017 522462701 Date: Endorsements: 3 Mailing Address: 2401 BARTELT RD APT Restrictions: NONE 2B Date of Birth: 1/1/1980 Mailing City/State: IOWA CITY, IA Sex: M 522462701 History Information Convictions Customer #: 5930422 ID Status: None DL Status: VAL CDL Status: None CDL Cert None Status: .02/12/2015 CDL Med None Status: IA Restriction None Supplement: Citetion Date Conviction Date ACD Explanation County Jus`e 01/25/2015 .02/12/2015 -M70 Improper Passing Johnson IA Name: Mohammed, Nasr Aldden Osman Oshar DL/ID: 582AH0582 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: �•'••'"":'r, 1i 6/2/2015 IOWA ='l D. 0. T..'% g r f'••"" Office of Driver Services Iowa Department of Transportation Name: Mohammed, Nasr Aldden Osman Oshar DL/ID: 582AH0582