HomeMy WebLinkAbout15-285t IDENTIFICATION NO. —
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i
CITY OF 101 ITYAPPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
{Police
41Q East 1�1'asbing ton Street Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
lova Ciro. Iowa 52290-1826 Failure io conJolete the "r
(319) 356-5040 eguir'ed i frrforrnation tvill result in denial of the application
(3 19) 356-5497 FAX
1. Name (FEQJIRE)I First Middle Last
2. AddressfRFpUIRED;
3, Contact Information (RFOUIRED) Email: ✓---i t=c,
r v' " Cell Phone:C 235
All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) X IS IS
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers:
6. Have you ever been arrested I charged with any misdemeanors and/or felonies in this State or elsewhere? _
Typeof offerse Where
n cE—:r 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? "J
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?
Type of offenses
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)
r'3 J
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STCrI= rFSZTIptFD
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
You m ust apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NbTA" Pula
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certihpp that I h� e issued to me by the iowa Department of Transportation a valid Chauffeurs license number
C) R`1 A ra y u issued on %.3644 —expiring on Q aA � 0 2 . I understand that if I
falsely answer any questions in this application, that this appication may be denied.Il 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
limes with all of the provisions of Title 5, Chapter2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant_ / Date_ i6
4*h#*H*kttb#4hhthkry#*k*kkxkhkhxk{Xhkkk*Hikkk33-k*k#Ak*skYx*kAxkxkx-kY-AxXkkk*kkR#*#*kky*****h!}tli#k*Ikkk#k3kkk*R#3*%h}y##{[k;tx'kkkkxhk#}y.*xxtak*
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by�
nb11 e this -- _. day of
1� � � N mogd xr saza TTVVotary Public th and for the Stale of wa
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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
Signature of is 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.
ASigna e of City Clerk or designee
'f
Dafe
wxts;*klkk*Mkk*!};3hN***#khx;lsk**k*kkk**k***ks***k}*.kxlklk},*ARRkf:h**k*RkIR*kksi*R!!y*kk-k#*kkkiy!}}#ksskki#*kx'ni*}xlxt!#}ikxlkxW*kkxsf k�*xkkx:r
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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03/2075
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SMARTER t 4iPAPLER 1 CUSTOMER I)C' V JNtIJUu.�Owado .gov
Inquiry
Date:
Customer
Name:
Address:
10/23/2015
1142265
Offco Of Driver SorvIC66
PO Bcr.9204 I pens Moines, 1A,%-7106-9204
Phone. 515-244-9t24 l 80fi-532-1121 � Fax: 515-239-1637
WWW. fawado'-gnv
Certified Abstract of Driving Record
DL/ID #: 082AAC05B(IA) CDL Permit Class: More
Class: D
Mohamedali, Modasir Audit #: 8489835
Khlllll
390 WESTGATE ST APT 5 Issue Date: 09/30/2014
Expiration 09/28/2022
History Information
CLEAR DRIVING RECORD
Name: Mohamedali, Mpdasir Khlilil DL/ID: 082AA0058
CDL Permit Issue None
Date:
CDL Permit
None
Date:
city/State:
IOWA CITY, IA
Endorsements: 3
Endorsements:
522463126
CDL Permit
Mailing
390 WESTGATE ST APT 5 Restrictions; NONE
Address:
ID Status:
None
Restriction None
Mailing
IOWA CTiy, IA
Supplement:
City/State:
522463126
Date of
9/28/1963
Birth:
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Mohamedali, Mpdasir Khlilil DL/ID: 082AA0058
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
None
CDL Permit
None
Endorsements:
IowaDepartme tof
Iowa Transportation
CDL Permit
None
Restrictions;
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit
EEG
Status:
IowaDepartme tof
Iowa Transportation
CDL Cert Status:
None
COL Med Status: None
Pursuant to Iowa Code 9321.10, 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:
1�. ----- ;r�iEy�4
IOWA'4
10/23/2015
D O.T.: gf
af'
w
of Driver Services
IowaDepartme tof
Iowa Transportation
Name: Mohamedali, Modasir Khlilil DL/ID: 082AA0058
10/22,'2015 12:33PM FAX 3193997302 0 0001/0002
lo0�i.21 2015.4 55 PNCabDiv of Criminal Invesiigalion No 9115 P, 1/2
• •• •• „ (FAX)319a,-,e2,w
2/002
STATE OR IOWACriminal Historye s;Che
Request t
Z)Cf Aocount Nurnhar: _9967-F
To: Town 131rlsl0n ofCrlmhfel ihywtlgetlan r1reppllceblo)
Support operations liareau, 111 Floor Front Xelio Cab of Iowa clry
21S R. 7u` ox
$trren p.0.8 45-
045 Molnes. Iowa 50319
(515)723-6966 Iowa City, 6124
Fexi 339-7302
V'%QVV%wne-aajz 1 M6410,&6e 1 KI�LL:A'
g1aS�iac.3 C�Ivmic [1Famalo ! Gam.-S�—1?3i�
rr"1wffrrnf0rmd(1M Without a signed waiver from the subleoC Ortho rogvwk a complete grlmihel history record may dot
be rataesaBlq porCode Otlowe, Cheptar 692.3, Sas*011113151e arlminei hiatoryreeortl tnfOrrMWaa, a7 eitowed bylaw, alwysye
obtain a wOloer tinotture hem the tablect of the raerroer.
td'dlver Release; t nraIn rlw pry data oe /or the abe4d rcquuilns Oinout to conduct w it" w MIP111 nitioty record oheck Wilt Oic Division efUndnet
(DCTI..Vry•erlminsr nlstaryeme genaarnln�r mu u munulnae I,y ihn t7C1 m.y La taloned u aNpwea oy nsw,
� 1 !
WaiverSlgtiaeurer
As of o-�1 a 30arah of the provlddd nano and data of birth
❑ No lows Criminal History R000rd found with DC7
lows Criminal Hixtaty Itaoord attached, DCi 9—. CtLq—cLiqo
DM initiala l ,1. 1
DCI -77 (OM5/19)
Received imt Oct,18, 2015 8:38AW No,0333
(CCI ate ani»
Ln
10/22/2015 7.2; 33FM FAX 3193397302
Oct 21, 2415 4;55PM Div of Criminal Investig5tion0002,0002
No. 9115 P, 2/2
01 ARRBSTMD 94130917
AGENCY; IA0520100
CHARGE NO- D2
ASSAULT
TRM IADOML702
COURT DISPOSITION
AGL'NCY! 13/0520153
COUNT NO- 02
CORALVILLE PD
IA STATUTE IA706.2(6)
JYORNSON CO DIST COURT
IA STATUTE; ZA700.2(6)
ASSAULT
ODURT CASE ID; 06521 AGCRID3031
CHARGE CLASS: NON CONVICTION
TRKY; IA00HL702
SENTENCE
FINEDISP
10NA CRIMINAL HISTORY
$300
20140310
DEFERRED JUDG4M6NT $109 CIVIL PENALTY
NDN CONVXCTION
DCI
00969990
DISCHARGED FROM
70141118
PASS
1 OF 3
DCI;OD95999D
DATE PRINTED.
9015/10/21
NAME; MORAMSDALI,MODASIR $HIL
DOB ssz RAC
HOT WOT Uyg HAIR
SKN
POB
19630928 M B
506 199 BRO BLK
DRK
YY
—�ADDITIBNAiTI88N'1�I-i�z-8R5
pHO,���;�L�x
CCU "CORD www
•-
01 ARRBSTMD 94130917
AGENCY; IA0520100
CHARGE NO- D2
ASSAULT
TRM IADOML702
COURT DISPOSITION
AGL'NCY! 13/0520153
COUNT NO- 02
CORALVILLE PD
IA STATUTE IA706.2(6)
JYORNSON CO DIST COURT
IA STATUTE; ZA700.2(6)
ASSAULT
ODURT CASE ID; 06521 AGCRID3031
CHARGE CLASS: NON CONVICTION
TRKY; IA00HL702
SENTENCE
FINEDISP
EPP DAT
$300
20140310
DEFERRED JUDG4M6NT $109 CIVIL PENALTY
10141118
PROBATION 2Y
DISCHARGED FROM
70141118
DS6'ERRED JUDGMENT
20141119
AN ARREST WITHOUT DISDOSITION I5 NOT AN INDICATION OF GUILT. THIS RECORD
MAxnTAINED BY THE IOWA DIVISION OF CRIrtINAL INVESTIGATION, BUREAU OF
IDENTIFICATION IS A PUBLIC RECORD HUT CAN ONLY 94 RELEASED TO NONrLAW
ENFORCEMENT AGENCIES BY THE DCI.
IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION TISIS RECORD IS
EASED ON INFORMATION FURNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD
COVSRS THE SUBJECT OF YOUR INQUIRY,
DIVISION OF CRIMINAL INVESTIGATION (P