HomeMy WebLinkAbout15-221CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED) 2
IDENTIFICATION NO. /,5 — :;t -;L C
(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
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Last
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3. Contact Information (REQUIRED) Email: Jor�ga—S" i hAmn l' a, Cell Phone: 31 `� — 333— 5.511
(All written communication sent via email)
4a. Chauffeurs License expiration date (REQUIRED) 69/. 1/� 4'w)
b. Taxicab Business Name (REQUIRED) J aWiWl j � x i ( 11Y
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? Al
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? ✓/A
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? ^/ O
Type of offense Where When
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9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prnde;thenai
DEPARTMENT OF CRIMINAL INVESTIGATION DCI REPORT AND STAT F + 1
{ ) TIED �.,
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF IEIM
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
D212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereb certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
5C,
C fit✓ 5 4 4issued on 12/2)/,2o il expiring on 0&l IZ2OIL—. 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 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 d 7/1542 .` jJi
**********k*************k**********'***kkhhhx**fe*fi*******x*************hh*k**kk*#HhT.hx*h**x***k************rt************x**M*#k*k*kh#*******kk**
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and swan to before me by Rj-,VmL, tl a� rc 1� f'5 to c- L , on this day of
,0. s WENDv S. MAYE RQ�R Notary Public in ah th State of —A,—
for
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).
Expirat' n date ha ffeur's license 6Y12���b
Signaturf P hief or designee 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.
Signatbre of City Clerk or designee
9-/5-1
,15
Date
clerWrMDRNBADGEAPPL92014zmended.Doc 03/2015
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State certified driving record
Website update
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215 E, T" Sfroe(
Ues Moines, Iowa 56.319
(515) 725.6066
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Phulte: 319-356.5041 —
pax: 319-356-5497
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^ �" uvrlrlilftrlplt: Without a signed waiver from Ihesubject pf(he reques[, a complete criminal history record mar oat
he releasable "----
per Cade oflowa Chapter 692.2. For col_ nnfete criminal history reinformation, as allowed by tats, nilobtafL nWa��cr sl ns[ure from cord the sub"net of there oast.
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mainlaiiuJ by the DCf may be Had os xllowtd by tem
li'rtiverSi�rrnlure: L `�-_�,���
Iota �rirrti►Iai i�tor I Record Check
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Received Tlfae Sep. 9. 2015 9,06W tlo. 7510
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SYARTER I 'HMR EF i CUSTON! J DRIVE'v.ne,,......� -. ,
Office of Driver Services
PO Sor 9204 Des Moines. 1.4 503064,204
Phone: 515-244-91231 "00-532-7321 I Fax'. 515-235-1937
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Certified Abstract of Driving Record
Inquiry Date:
9/9/2015
DL/ID S:
569AG6549 (IA)
Customer rt:
5909707
Class:
D
Name:
Osman, Mohamed Ibrahim
Audit 7t:
5696549
Address:
2425 BARTELT RD APT 2C
Issue Date:
12/21/2011
CDL Status:
None
Expiration Date:
08/21/2016
City/State:
IOWA CM, IA 522462709
Endorsements:
3
Mailing
2425 BARTELT RD APT 2C
Restrictions:
NONE
Address:
f"'
Restriction
None
Mailing
IOWA CITY, ]A 522462709
Supplement:
City/State:
Date of Birth:
8/21/1966
Sex:
M
C -n
History Information
Convictions
CDL Permit Class: None
CDL Permit Issue None
Date:
COL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
LDL Permit
None
Restrictions:
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status: None
CDL Med Status: None
-itation Date Conviction Date ACD Explanation County IUR
)2/16/2015 03/22/2015 S92 Speed Johnson ]A
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a Citation.
Accident Date Case Number
]UR
05/12/2014 798599
IA
Name: Osman, Mohamed Ibrahim DL/ID: 569AG6549
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;
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Name: Osman, Mohamed Ibrahim DL/ID: 569AG6549
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9/9/2015
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Office of Driver Services
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Iowa Department of Transportation
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