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CITY OF IOWA CITY
410 East Washington Street
Iowa city. Iowa 52240-1 82 6
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
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
3. Contact Information (REQUIRED) Emai
(All
4a. Chauffeur's License expiration date (R
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers:
Middle
r
cur
commun
- I
email)
Cell Phone:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
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? A/0
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
S. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where
When
AJa
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide therrame(s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATERTIFtED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE QHhF RFoVIEU1li^'f
You must apply for an individual Department of Criminal Investigation Report (form avaifab% ui request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have i sued to me by the Iowa Depart ent of Transportation a valid Chauffeur's license number
issued on xpiring on o1- d- 7 n� . I understand that if I
falsely answer any questions in this application, that this application 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 ofApplicar(t m{aS ��^-�" `1 Date �2 2e)1:5
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 4VV\lS�c� F_ Ow_z-� on this day of
MeehvlA�ti %4�15
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)).., n
Ex iration date of Chauffeur' cense 1 v d
�'L l
Signature of Polic Chief or esi bte
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.
Sign of City Clerk or designee
Datcf
Cl.hTAXIDRVBADGEAPPL9214amended DOC 0312015
Office Use Only —
r
Approved application
DCI report
State certified driving record
rn
Website update
Cl.hTAXIDRVBADGEAPPL9214amended DOC 0312015
iu'f"AnnT
vill
i�6i'14LiY. "iNk'V iowa .io�.go
Office of Driver Services
RO Box 9204 i Des Montes, iA 50306-92011
Phoerr 515-2144- 9124 J &0i3=532-1124 i Fay: 4 I5-339-1837
www. [owada4 dov
Certified Abstract of Driving Record
Inquiry Date:
12/2/2015
DL/ID #:
748M4707 (IA)
COL Permit Class:
None
Customer #:
6158288
Class:
D
CDL Permit Issue Date:
None
Name:
Omer, Mustafa Elhadi
Audit #:
8956276
CDL Permit Expiration
None
Date:
Address:
1311 SOUTHVIEW CII[
Issue Date:
03/26/2015
CDL Permit Endorsements:
None
_I
Expiration Date:
01/01/2023
CDL Permit Restrictions:
None
City/State:
CORALVILLE, IA 522411046
Endorsements:
3
ID Status:
None
Mailing Address:
1311 SOUTHVIEW CIR
Restrictions:
NONE
OL Status:
VAL
Restriction
None
CDL Status:
None
Mailing
CORALVILLE, IA 522411046
Supplement
CDL Permit Status:
ELG
City/State:
Date of Birth;
1/1/1970
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
CLEAR DRIVING RECORD
Name: Omer, Mustard Elhadl DL/1D: 748AJ4707
Pursuant to Iowa Code §321.10, 1, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I am the custodian of the records hard by the Office
of Driver Services, that this is a true and accurate copy of an officlal 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:
Name: Omer, Mustafa Elhadi DL/ID: 748AI4702
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12/2/2015
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Office of Driver Services
Iowa Department of Transportation
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STATY OF IOWA
! r Requing Forril
T0: Iowa Div War, of Criminal Investigo)lotl
5uppori Operotiom Bureau, I" Floor
215 E. 7" Street
(515) 774-6066
(515)i25-60$0 rar.
Criminal HistmyRecord Check on:
Last dame (Snandalory)—
O m,e-i
Date of Birth (mandmory)
I]C;r Account 1Vumber: _ NOO�"�
(i(appliceblc) ---
From City of Iowa Citta .
City Clerk's office
Iowa C;�, Iq g22Rp--•V-----.---
Phone; 319-356-5041
Pax 319-356-5497 --- --
effale Elyemale
'qG2 - 30 — _?/E 9
Waiver Without a signed waiver From the subjeot of the request, n complete criminal history recerd may not
be releasable, per Code of IOWA, Chapter 6921 For eo?nblete criininsl history record informat;ou, as allowed by lana, always
obtain a tvalver slrnatw a from the enhirm of ehc � e....e�.
Waivpg,Release:I herebygivepenlliSSlonfor dm Atcvc fegjIu'lieg0fr1cial la conductan logo Cflminel hiSloq�reeard check wiIh the Dii6o06 Criminal
im¢slig0tl0n (DC1), Ally crimiml Irslop'deta mllftmina me thsl n maintoin�ed by th�DCI loay'be released as a moved by IAw.
6l'aBverSiennture:-����Y����-�,���_�_-
Iowa Criminal Histor Record Check Results y)
(DCAlistonly)
P
As of- n
a search ol'the ro`rided 11ai11C and date of birth ret+ealetl: '
]oto lnAVa Criminal hlisiory Record found wilh llC1
lo�tra Criminal History Rccord attached, ISC:1 / o`
J& -lie J '
DC:1 initials
( )--"-•--.- ..--.. _..-.. .�...-.... ..........—_ � PTS-...._
Received Time Nov, 25. 2015 4:25PM No. 2784