HomeMy WebLinkAbout15-260CITY OF IOWA CITY
410 Last Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO.. 1 15--,� (a (p
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB 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
First
3. Contact Information (REQUIRED)
Middle
Last
°i✓"11� St Cell Phone:l
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 1
b. Taxicab Business Name (REQUIRED)__ (vw
5. Prior experience in transportation of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type cf offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? rel 0
Type of offense
Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
Has your driver's license or chauffeur's license been suspended or revoked in the last five years? _LJJ
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)
rel J
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STaTF r-FRTtFeFn
ti DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF�REVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND N6T- A" 20115
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby cerci that I h ve issued to me by the Iowa Department of Transportation a valid Chauffeu's license number
C-> 5? `a Acru issued on o expiring on � _ of I understand that if I
false) answer an �` ` — p g g-1—��
Y y 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 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)
Signature of Applicant / Date 6 a3
Fl,
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me by tVA, O Ce S, r ��?
21)1!L by this day of
WENDY S. MAYFR
the
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 �/ ! �`��`'y �✓
Signature of(7 a or designee
�0�2320 )-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.
�`lClct��i�c� `7�
Signature Of City Clerk or designee -
Office Use Only
1_0 /
'Date
r_
Approved application t 9 7c'13
DCI report
State certified driving record
Website update
CIer4✓rP.XIDRIVBADGE PPLM141mentled DOC
03/2015
7410WADOT
SMARTER t SOAPLEP I (USTOMEF GRMN WV1/WJok1Jadct.g0V
Inquiry
Date:
Customer
Name:
Address
10/23/2015
1142265
Office Of Driver services
PO Box 9204 i Des Moines, to 50304-9204
Prime- 535-244-9124 1804-532-1121 I Fare 515-239-1837
www.iowadoLgov
Certified Abstract of Driving Record
DL/ID #: 082AA0058 (IA) CDL Permit Class: None
Class: D
Mohamedali, Modasir Audit #: 8489835
Khlilil
390 WESTGATE ST APT 5 Issue Date: 09/30/2014
Expiration 09/28/2022
History Information
CLEAR DRIVING RECORD
Name: Mohamedali, Modasir Khlilil DL/ID: 082AA0058
CDL Permit Issue None
Date:
CDL Permit
None
Date:
City/State:
IOWA CITY, IA
Endorsements: 3
Endorsements:
522463126
CDL Permit
Mailing
390 WESTGATE ST APT 5 Restrictions: NONE
Address:
ID Status:
None
Restriction None
Mailing
IOWA CITY, IA
Supplement:
City/State:
522463126
Date of
9/28/1963
Birth:
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Mohamedali, Modasir Khlilil DL/ID: 082AA0058
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
None
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
Iowa Department of Transportation
ID Status:
None
DL Status:
VAL
COL Status:
None
CDL Permit
ELG
Status:
CDL Cert Status:
None
CDL Med Status: None
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:
.............#'11
10/23/2015
IOWA
D.O.
T.
. ,
°e_
f BR1R
Office of Driver Services
Iowa Department of Transportation
Name: Mohamedali, Modasir Khlilil DL/ID: 082AA0058
10/22/2015 12:33PM FAX 5193997502
10 dct.2lr_ 20155 4�55?M Cab of Criminal Investigation
20001/0002
(FnX)319=2NO, 9115 P.� 1/21i002
STATE OF .
Criminal History Record Check
is
Request Form
DCI Account Number: _9967-F
To; Iowa Dlvlebn of CrImU)el Invwtlgetlon (irapoucabh)
Supper t Operations Bureau, 1" Flaar From; P o" Box 428 f xowa City
215 A- 7Street
Des M0111e8, Iowa $0319 Iowa City, IA. 6224
(515) 723-6066
' Phenol .••—_._
Faxl (319)339-7302
�AOVAAW1e_ao-Li MadaSir VIVv , A'
Date of Hirthttnrndemy) Gender ansate -80cial-Securi Number leoemmmded)
q! �$/ 1q�.3 IAMale ❑Female GP�q
Woiverinformarlon: Without a signed waiver from tho subieat o(the rogpest, a cc
mplgte grlmtno! history record may
he rolaosablot por Code *flown, Chapter 682,2, Par cemntele criminal hletoryreeerQ information, e9 allowed bylaw, alays not
R
Ohtein a WaIVlr dlanelar! nm the ruhrntr am. rnd"aar
If'alver Release; I hatnby slw permisflte hr lho abate « qucrOng 91110111 to condool w IOwe crlmhnl hlllory record ohcok will the Dlrirlon afCrlminel
tnv;.rlgaa9t (nCQ< Artycrlminal blatorydate g9naarnlry.,�s that u melnulnad by the Del may b9+oloucd as atlawaa bylaw;
� 1 1
Waiver Slg)rururet
--
As of Qom_
a search the
(Del use only)
. of provided name and date of birth
ravaeledt•,
❑ No Iowa Criminal History Rocord found with DCI
v
r
,.
P 1
Iowa Criminal Fiixtnty Reacrd attached, DCI K .,-E5
1-i
DCI initials �,n
���
1—
DCI-77 (08/25/10)l
2
Received Time OcI 18. 2015 8:38AM No, 0333
10/22/2015 12:33PM FAX 3193397302
Oct.21. 2015 4:55PM Div 0f Criminal InveStigation
IOWA CRIMINAL HISTORY
NOW CONVICTION DCI 00989990
PAGE I OF I
DATE PRINTED-
DCI:00989990 2015/10/21
NAMES NORAMSDALI,MODASIR RHIL
DOB 887L RAC HOT WGT RYS HAIR SKU POE
1963 D928 M B 506 199 BRO BLK DRK Yy
U0002/0002
No. 9115 P, 2/2
—�ABDIfiIONAiTIBBNR�j-F3-HRS PHOTO-kVAT1aAgIa1� M
CC$ RECORD — '-
01 ARRHSTBD 20130917
AGENCY; IA0520100
CHARGE NO- 02
ASSAULT
TRKOi IAOOHL702
COORT DISPOSITION
AGENCY: 1A052015J
COUNT NO- 02
CORALVILLE PD
IA STATUTE ZA700.2(6)
JOHNSON CO DIST COURT
IA STATUTE; IA708.2(6)
ASSAULT
COURT CASE ID: 06521
ACCRIO3032
CHARGE CLA68: NON CONVICTION
TRK#; IA00BL702
SENTENCE
FINE
DTSP EPs PAT
$100
20240310
DEFERRED JUDGEMENT
$100 CIVIL PENALTY
20141118
PROBATION
2Y
20141118
DISCHARGED FROM
20141119
DEFERRED JUDGEMENT
AN ARREST WITHOUT OZVOS.ITION IS NOT AN INDICATION OF GUILT. THIS RECORD
MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF
IDENTIFICATION IS A PUBLIC RECORD EUT CAN ONLY SB, RELEASED TO NON,LAW
ENFORCEMENT AGENCIES BY THE DCI.
IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS
BASED ON INFORMATION FURNZSHED, WE CANNOT CONFIRM OR DENY THAT THE RECORD
COVERS THE SUBJECT OF YOUR INQUIRY,
DIVISION OF CRIMINAL INVESTIGATION Qp