HomeMy WebLinkAbout15-258t"� l IDENTIFICATION NO.
(Office Usee Only)S
CITYOF 1- CITY APPLICATION FOR TAXICAB /
(Police Department review MOTORIZED PEDICAB VEHICLE DRIVER
410 Easl Washington Street must be
lova Cily, Iowa szz4o- made between 8 a.m. to 3
(3 19) 356-5040 1 sz6 Failure to com fete the " p.m., Monday -Friday)
re wired ' information will result in denial „s.<_
(3 19) 356-5497 FAX ._
1. Name (REQUIRED) r'rYt k I°
2. Address (REQUIRED) Z 1D C1
3. Contact Information
(REQUIRED) Email:
1r11 written communication sent via email) ell Phone: p -
4a. Chauffeur's License expiration date (REQUIRED) ZU -
b. Taxicab Business Name (REQUIRED) -f
5. Prior experience in transportation '
of passengers
\\A O.
6. Have you ever been arrested /charged with an �e
Tvpe o_ p- Y misdemeanors and/or felonies in this State or el�h ev e k
Where
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended
Plead Guilty Other
Have you been arrested / charged with an
Ty ov f� Y traffic offenses in the last five years?
Where
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Plead Guilty Other
Type o� f- i
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)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI)
REPORT
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF
AND STATE CERTIFIED
REVIEWYou must apply for an Individual Department of Criminal Investigation Re
(SECOND PAGE FOR Port (form available upon request).
REQUIRED SIGNATURE AND NOTARY) J J
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby e fy t t 11h ve issued to me by the Iowa De artme t of Trans ortati n a vali Chayffeur's license number
6';i2_y 4 1 j issued on �xpiring on �b I understand that if I
falsely answer any questions in this application, that this applicatio may be denied. I agree t at in making this application, 1
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 provisionsefT ---,Z, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date tC—ZZ —Zo1Cj
STATE OF IOWA )
COUNTY OF JOHNSON
Cs�scrl ed and savor to before me by �'Z�<i r S i d— � on this �2 t day of
��I`�]/
{ �khr KELLIE K.TUTfLE
commie;- um� V Dl(eS19 otary Public in and for the State of Iowa
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 bq 20 l20 1 t
_,-J*I LC)3
Signatureof Poll e Chief or designee
�ozz�s
Date
AFTERAPPROVAL 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.
-,A �, - 4
Signature of City Clerk or designee
Office Use Only
'Date
Approved application
DCI report
State certified driving record '.
Website update
Clerk(TAXIDRIVBADGEAPPL92014 mende DOC 03/2015
Oet.21. 2015 12'�21PM Div of Cflnilnal Investigation NO. 9058 P. 1
r. ...J 10/16/2016 in .'aob 1.002/002
STATE OF IOWA
�.� Criminal History Record Chepk
Request For'M
DC1 Account'Nwnbe;: lt
l --
(if applitablo)
'1'n: Toa:a 1livision pf Criminal Lrves¢igation From: _ Ci(y of Iowa Cifv
Suppart Operations Bureau, 1" Floor City Cldrl('s OfficC
215 P, 7" 33trett al0> . 4elashbtglon 3ftdet
Des Moines, Iowa 50379
1 -- hl17?2-Chy7tA—nT4
(515) 755-6060 Fax ---'-"-'�-
1 Alli requesting an Iowa Criminal His
S �4a� w -ea
O q --Z0 ^ 1 C�5—�
Phone: 319-356.5041 _
Pax: 319-356-5497 —
Record Check
First Name
ShCk-l�\r
Gender
Able ❑Female
uule INMe (recommended)
Md ver rriforrrfafJoil: Without a signed waiver from thesubJect of the request, a comptote crilnlnal hislory record may not
be releasable, per Code of larva, Chapter 692.2. Por complete crhnlual history record information, as allowed by lacy, allvays
obtain a waivel- signature from the sub iect of the reouest.
Waiver Release; 1 hereby give pcmifssion for die above regvcsting official to condacr m Iowa criminal hisloryretard che04• millithe Oivision ofCrimniel
rm•esligation(DCI). Any criminal history dataconecmingn ma,,,,wdby the OClnlay be released as allowcd bylax.
Il"aiverSigizatin-e
Iowa Criminal History Record Check Results
�
As of ��a search of the provided Marne and date of bi11h
revelled:
(I)Cl use only)
No loisra Criminal History Record found with DCI
.rc-1
❑ ]oWa Criminal History Record attached, DCI
c,
bCi initials
co
UU1-// (w)jf 10)
Received Time Od 15, 2015 4,31PN No -0281
r
;�fZ k ^ ..ts „bl DGT
,N"r Ai),1*f . t o Vit ado t 01f
"•--•fir =tih ay„(iC'G fi r; jr �,e'” i�'v=TO ^A:.i I office of Dnver Services
P4 Box 9204 ; Des ?,,401711° i 03f6-9234
Plane sf5-244u124IMOO -532-1121 1 Foe 1111 -239-IS37
ww'w iowii+. o"_gov
Inquiry 10/15/2015
Date:
Customer 5846338
#:
Name: Sidahmed, Shakir
Mohamed
Address: 2509 BARTELT RD APT
1D
City/State: IOWA CITY, IA
522462715
Mailing 2509 BARTELT RD APT
Address: 10
Mailing
IOWA CITY, IA
City/State:
522462715
Date of
4/20/1957
Birth:
Office of Driver Services
Sex:
Ni
Certified Abstract of Driving Record
DL/ID #: 532AG5413 (]A) CDL Permit Class: None
Class: D
Audit #: 5450123
Issue Date: 08/17/2011
Expiration 04/20/2016
Date:
Endorsements: 3
Restrictions: NONE
Restriction None
Supplement:
History Information
CLEAR DRIVING RECORD
Name: Sidahmed, Shakir Mohamed DL/ID: 532AG5413
CDL Permit Issue
Date:
CDL Permit
Expiration Date:
CDL Permit
Endorsements:
CDL Permit
Restrictions:
ID Status:
DL Status:
CDL Status:
COL Permit
Status:
CDL Cert Status:
COL Med Status:
None
None
None
None
None
VAL
None
ELG
None
None
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of office of Driver Services, Iowa Department of Transportation, do
ffice of
ver
curate copy Of
hereby
c certify that I am the ceeptly n the odistotly of said office, held
tlnd that by eI have been authorized uthorri eldeby the tDirectorr of ths is a truee Iowa nd cDepa Department of
an rd
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 data:
Z "1
10/15/2015
{
D. 0.
.;
9 ••....�'g
Office of Driver Services
�f �i�A=�
Iowa Department of Transportation
__. I,
Name: Sidahmed, Shakir Mohamed DL/ID: 532AG5413