The URL can be used to link to this page

Home My WebLink About15-282I r 1 a riuly®r®1\ CITY OF 1OVVA CITY 410 Last Washington Street Iowa City. Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. ! �—, — 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 First Middle Last �P,( Cf1 2. Address (REQUIRED) _'9111 ;;d TA =;;; 4 j 3. Contact Information (REQUIRED) Email: Cell Phone: if�S h fC1 I (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) U�� 2�)� b. Taxicab Business Name (REQUIRED) _ y l flv ( A Ij jewcr r; i 5. Prior experience in transportation of passengers: Op krc3K �of ✓ 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? /7 1/ 8. Type of offense What happened to the charge? (Circle one) Where Convicted Dismissed Deferred When Suspended Plead Guilty Other — won Have you been arrested / charged with any traffic offenses in the last five years? Type of offense What happened to the charge? (Circle one) Convicted Dismissed Where When Deferred Suspended Plead Guilty Other — (yort c Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Type of offense Where When ry W� . 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prwudec th�ame(s— „i DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATECRRTIFtED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW Nw You must apply for an individual Department of Criminal Investigation Report (form available upon request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02/2015 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 issued on /x / expiring on 7 / . I understand that if I falsely answer any questions in this application, that this applicaftion may be denied. I agree t at 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 A� <S Clyr K� S q v c� Date 171 1 s 1 1�5— STATE OF IOWA ) COUNTY OF JOHNSON ) S bscribed and sworn to before me by 42G . in on this r3 V -7t--, day of 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 -g f Zb�lo !.I " Signature of PolicChief 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. SignAtufe of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update ///ice /i, Diate Fes+ Ga Gal cledd MDRm9ADGE PPL92014..e�ded ooc 0312015 1iNov10. 2615;, I,24PK, CaeDiV of Criminal Investigation (FAX)3193300, 6669 P. , 1.002/002 •wSTATE OF IOWA 'r ' Ile ' r eCheck I , Request Form To: iowa Division OrCr(m1nal Investigation Support Operatlons Bureau, to' Floor 215 E, 7's Street Das Molnts, lowe $0319 (515) 725.6066 Nb SIIQ>� DCI Account Number: 9967-F . (troppllrable) prom; Yanow Cab otlowa City P,O. Box 428 XOwa Clry, IA, 52244 Phone: Fox; (319)339.7302 05man J-»...+��wu a.wwonr;mwmmanacd O�/��1 i��A' L�a1e I�h'emale Ga3-dq-�GD� rralver,thjarMafion, Without a signed waiver from tho subject or the request, a complgto vrlminai history record may not be relonsabla, per Code orlowa, Chapter 693.2, For comnicl arlminai history -record Informatlon as allowctl b obtalh a walver signature ham the snhlece er rh. ra ,. Y law, always Walyer Release: 1 hereby give per(nlesron for the above requestingomoid to conduct an lows odminal historyf0eord check whh the M41on ofOr! telnd 1gMlgadnn DC-jspy.virnwihist orydaleoanaem(ngma;het13nnl einedbythe°Clmeybenlcueduellowatlbvlam. Waiver Sigrralare; As °f 4 5 B search of the provided name and date of birth reyyaled: No Iowa Criminal History Record found with DCI L7 'i ❑ Iowa Criminal History Record attaohed, DCI # t on DCI initials DCI -77 (0Bi25110) Received Titne h11ov, 6. 2015 4:14PN No, 1612 (ort are only) CD 4 C, . WADOT SMARTER I SIMPLER I CUSTOMEI' DRIVEN 1NWW101Uc11�Ct�. SIV Inquiry Date: Customer #: Name: Address: Page 1 ot'2 Office of Driver services PO Box 9204 7 Des Moines. EA 50 -5204 Phooe. 515=244-5124 1800-532-1121 I Fax: 555-239-1837 www_l'iwadot.gov, Certified Abstract of Driving Record 11/6/2015 DL/ID A: 560AG8796(IA) CDL Permit Class: None 5895512 Nogod, Hisham Mohamed 991 22ND AVE City/State: CORALVILLE, ]A Class: D Audit 4: 5608796 Issue Date: 11/02/2011 Expiration 07/28/2016 Date: Endorsements: 3 Restrictions: NONE Restriction None Supplement: History Information CLEAR DRIVING RECORD Name: Nogod, Hisham Mohamed DL/ID: 560AG8796 CDL Permit Issue None Date: CDL Permit 522411508 Mailing 991 22ND AVE Address: None Mailing CORALVILLE, IA City/State: 522411508 Date of 7/28/1979 Birth: None Sex: M Class: D Audit 4: 5608796 Issue Date: 11/02/2011 Expiration 07/28/2016 Date: Endorsements: 3 Restrictions: NONE Restriction None Supplement: History Information CLEAR DRIVING RECORD Name: Nogod, Hisham Mohamed DL/ID: 560AG8796 CDL Permit Issue None Date: CDL Permit None Expiration Date: None CDL Permit None Endorsements: COL Permit None Restrictions: ID Status: None DL Status: VAL CDL 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: IOWA ).0.T Name: Nogod, Hisham Mohamed DL/ID: 560AGS796 11/6/2015 ^^� Office of Driver Services-'"• "'. -- Iowa Department of Transportation—t"" C :t. 11/6/2015