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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(3 19) 356-5497 FAX
IDENTIFICATION NO.
(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 Middle
1. Name (REQUIRED)Yl S M1RSA i"16Qtnnlm
2. Address (REQUIRED) 26S`U PobeytS P -a ADT # i a JDWc% t+ut I {i 52-2-
3.
LZ3. Contact Information (REQUIRED) Email: bcibah akeem 2=52o3 0 kAwwt% -co Cell Phone(3 t9)5 t 2 -i,b3I
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) 514tppk 2Z Z l{,
b. Taxicab Business Name (REQUIRED) �, 1 i LI (q ♦ j
5. Prior experience in transportation of passengers:
PC Areca %or Imore tkan-7l `j'ar - Ih I6Wr( Cll cC)yCC0V1((e
larn 2a17_ -
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere NO
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
What happened to the charge? (Circle one)
Where
When
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?
N
Type of offense Where Wben
c
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the 11ane(s). Al
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CEP
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
S t44 65
1 17 issued on OT12312 aliexpiring on oL I zz I ze I-6 . 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 Niitle 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant %tV2 Date LCI 30. 2015
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me byt,-Cir;t, L4 kekamam ---o on this 3o day of
201 A
T°u�m YVENbY S. MAYER 1� S ~�`t`^
compq mission Number �zeaze Notary Publi$!in and for the to c 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
J,9su,- old►
Signature Police Chief 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.
Signa of City Clerk or designee
14 "12,! /�-
D e
Office Use Only
0
Approved application s- _ C--) N ` .4
--4
DCI report n W
State certified driving record o rtrt�
Website update n
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SNIAR ER I Jf"rif�1_`.F I iU'TWA'-� PRI5 FAV w
Office of Driver Services
PO Box 92D4 ; Des Montes, lA 50306-4204
Phone: 615-244-01241800 L32-1121 i Fax: 615-239-1837
www.iuwadot.gov
Certified Abstract of Driving Record
Inquiry Date:
10/30/2015
DL/ID #:
544AG5717 (IA)
CDL Permit Class:
None
Customer #:
5867187
Class:
D
CDL Permit Issue
None
Date:
Name:
Mohammed, Faris Musa
Audit #:
5999364
CDL Permit
None
Expiration Date:
Address:
2654 ROBERTS RD APT 18
Issue Date:
05/23/2012
CDL Permit
None
Endorsements:
Expiration Date:
02/22/2016
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522462741
Endorsements:
3
ID Status:
None
Mailing
2654 ROBERTS RD APT 1B
Restrictions:
NONE
DL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522462741
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
2/22/1965
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
CLEAR DRIVING RECORD
Name: Mohammed, Faris Musa DL/ID: 544AG5717
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:
;•""'•'••',�/do ���
10/30/2015
IOWA z s,
D. 0.
...... y
01 Sh
hAft
Office of Driver Services
���w„--
Iowa Department of Transportation
Name: Mohammed, Faris Musa DL/ID: 544AG5717
Oct.13 2015 361IN Div of Criminal investigation No. 8549 P. 2/2
F,.—:Clty of 1.w. Cuy Cf.", QlfiGe 319 3665497 1U /'12/2D 15 15. -❑6 0296 P.CtD2/002
STATE'OF IOWA
Cri1)lillaf History Record. Ch6 (:k
,4'equesi Form
D(I /�ccoum 1Jumbcr: 0
(if AppliuGhle) ---�
'1'u: lawn BivWtin nrC'rirrlinal lrsvesll a(iou
g j4•rrri: Cify of Ie
rsupporl Optrationsl�ureauW'a, i"Floor--_—__-.__._..._.._.....
21,112. 7" titraef City Clerb': OFALe
410 E. Washiu fon S'fret[
1)es Moines, !ouch 50"319 —
(9F5) 77,5-6066 --„ _
(5F5) 725-6080 Pax— --- ..— ...._...._.
1 am requesting an IOVV9 C
Last ]Na1nf pnanasmn9
M.o l�o.m r„zd
Date of Birth pnaneamry)
02/22) jq66
Phone: 319.356-504) _
Fax: 3t9-356.5497 —_
First
tatMale E]Fentale
MU
ber
X32-12-3133
rt,otrer UiJorma(ion: Without a signed llaiver from the subjee( ofthe request, a comple(ecrifniaet hisiory record ma)• nol
be releasable, per Code of lows, Chapter 692.2. For comniete criminal his(lay record information, as allowed by law, alrcays
obtain a rwaiver signature from the subicer of Ino-
Waii,er Release: i hereby Dien pennrss on for she above rcgl,eadng official to conduct an IMA criminal Ilislcn' ftcord Check wish da Division of ervioal
Inve$ggalion(DCI). Anymnainel hisloly dala eoneemine me!hal isrnainhoed byshe DCl may be released as allowed bylaw,
xoWa Criminal Hianr Pecol•cl Check Results
As o1'_— /0 la ' a .sea) ch of (he provided name and date oj'birth revealedr
4.1
No Itlwa (:Timival liisuu'y Record found with llC:j
losva C'rimioal History Record attached, DC'l #I_
1.)(l initials,.
1)(A-77 (08/25!10) ___'-----------•—.— --..^
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