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CITY OF IOWA CITY
4 1 D Fzsr Washingi Street
Iowa CII;, lvwa 52290-1826
(319) 356-SD40
(319) 356-5497 FAX
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IDENTIFICATION
NO.
(Office Use Only)
APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 P -m., Monday - Friday)
First
1. Name (REQUIRED) _
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2. Address (REQUIRED) _ n T S A t 5�A ev-
3. Contact Information (REQUIRED) Email: b (cc,�-
(AII written communication sent via
4a. Chauffeur's License expiration date (REQUIRED) _%� 6 f Q 'Zfj
b. Taxicab Business Name (REQUIRED) -A } Y1iiin
5. Prior experience in transportation of passengers 4 I i°GtY
Las
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6. Have you ever been arrested I charged with any misdemeanors and/or felonies in this State or elsevig'? e,5
lype of offense Where
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dja<rd
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What happened to the charge?
g _ (Circle one)
Convicted Dismissed Deferred Suspended
Plead Guilty Other
7. Have you been arrested/ charged with any traffic
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offenses in the last five years?
LR oP offense
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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? — _
Tyne 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 provide the name(s) '
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
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
2-J Wfu
E:nat I have issued to me �y the Iowa Department of Transportation a valid Chauffeur's license number
issued on
answe an expiring on G 2oZ3 - I understand that if I
falsely y questions rn u,10 :7 . ,,,ceuun, that this application may be denied. I agree that in making this application, l
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 furher agree that, if authorvation to be a taxicab driver is granted, to comply at all
times wish all of the provisions of l Me 5, Chapter 21 of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant_ Dale b 2 U 5
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STATE OF IOWA
COUNTY OFJOHNSON )
Subscribed and sworn to before me by \ i�ongth on this -DQ day of
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c in and for the Stateaf Iowa
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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 thatthe 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 �r� �zms
6 S2o S
Signature of olic Ch for designee Date
4
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOM�r
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. CIL FOR
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Signature of Ci Clerk or designee
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Office Use only
Approved application
DCI report
State certified driving record
Websfte update
civarnxi oamenoc>Enn.uso ak„,�a�d. ooc
0372015
CAIowa Department of Transportation
0"Ice at a7rwa sera es 1 To9f Fr®e) UMF532-t tit
PO faux X204, 6D3 Mat as, u1 F^ 3[ 5 92(w 515.244-4124
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Certified Abstract of Driving Record
Inquiry Date:
8/19/2015
DL/ID #:
43SAFS256 (IA)
Name:
Mohammed,
Class:
D
VAL
Ba Fakat Fa yeery
]ahnsan
CDL Status:
Address:
128. SlVISHER ST
Audit #:
38314^30
None
]ohnson
Issue bate:
02/10/2015
City/State:
-OWA CITY, IA
Expiration Date:
06/10/2023
None
5224515".?
07/00/2014
Supplement:
ca
Endorsements:
3
Mailing Address:
PO BOX 34a
Restrictions:
NON[
Date of Birth:
5/10/19111
Mailing
IOWA CITY IA
Sex:
M
City/State:
522440.342
History Information
Convictions
Customer #:
562b613
ACO
ID Status:
None
Type
DL Status:
VAL
eed
]ahnsan
CDL Status:
None
1/2017
07/25,2012
CDL Cert Status:
None
]ohnson
r1A
CDL Med Status:
None
592
5 eed
Restriction
None
�0�/201a
07/00/2014
Supplement:
ca
-
w
Citation Date
Conviction Date
ACO
Ex lavation
Count •S525
Type
Effective
End
eed
]ahnsan
ence
1/2017
07/25,2012
S92Rpeed
(10 mph u
under in 35-55 mphzone05"24/2014
]ohnson
r1A
01?06/2015
0,/132014
592
5 eed
Jonnson
Johnson
�0�/201a
07/00/2014
104 Seat eeft'Violation
Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Sanctions
Name: Mohammed, Barakat Fageery DL/ID: 435AF6256
Type
Effective
End
ACD
Explanation
ence
Suspended
—
01?06/2015
07/05/2015
051
Non -Payment
-h;ld Su ^ort
FIA
Name: Mohammed, Barakat Fageery DL/ID: 435AF6256
Pursuant to iowa Code y`321.10, 1, Kim Snook., Director of Office of Driver Services, Iowa Department of Transportation, do
hereby certify that I am the custodlan 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 o` 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 he set upon this document, at Ankeny, Iowa
this date:
8/19/2015
D. O. T `a sf
k
Office of Ohpar Services
Iowa Department of Transporation
Name: Moharnrned, 6arakat Fageery DL/ID: 435AF82Sb
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STA Tr, OF WWA
('7-ifr7ifla) Ijrsfo7'y LtN"W'd cilech
I�l'(tlies€ Form �
to a1)iri.fun 01'Crlm ilia l L"•eatifuticn
SuPror( OPeraiioas Fiureau, f" C+loa
215 L 7'" Street
D"' h' tiros, Iowa 50319
(MS) 715•im
(515)'125-6080 Nae
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7 Clcrli's ll7rce
470 Ci, Washfngta�i 5trcct
7UWa Com; A 52246 o M4--
Phone:3J9.3S6-?;G41 CT
Fax:——
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ta7
�hlsle Qemale 5 7 `f [s �-7
�• .ly urrtrmtOn: Wi{hout a signed eaiver�-~
be releasable, per Code orjow/ Ch 7roh'the subject of the re ucst,
obla h as w_atver si ` after 69x.2, Fm• ¢o_m ilele criminal history
9 complete crinin Ai history record may hof
nature Jrosa 111t, sub act of 1ho re uesl. record information, as allowed by law, always
Waiver Release I
Nvtnigaola,{DLi). Anyerlmi+0h';lury�dd'e�ep,j¢ery'm,g'na'hal to m:inla dyli�coUCl ntsylaevfNeatvlys stolydhrlaw.
afminel bisrorytabard ch�cM ,vii Nc Division of cnl4 al
N/rti'�cr Sibunalrrre; r�'
Iowa Cr"Bl"al Histor Reeord Check Re
As o!'--- �Hila nsc anlll
+ sea' p11 of the provided Hanle tiltd dale of rl11 revealed:
N'C Ipwh (-_'rinunal Histol=: 'n
� Recnt'd found with llCy r:' r. -i
laevo Criminal ll;slor)rltc[urd all�ohed,
r-
PPCe4el Time Aug, 13 2015 1 46PN N'o.5499
4ug.14. )(1115 4;45PY Diu of Criminal Inrsstig�'r,ur
IOWA CRIMINAL HISTORY DCI D0954934
MISDEMEANOR CONVICTIONS ONLY PAGE 1 OF =
DATE PRINTED—
DCIc00954934 2015/00/7.8
NAME; MOHANNED,BARAKAT FAGE)ERY AHMED
DOB SER RAC HGT WGT EYE HAIR SKM POB
19710610 M E 509 150 BRO ELK DRK YY
�o5168
ADDITIONAL IDENTIFIERS PHOTO AVAILABLE; Y
CCH RECORD **i
01 ARRESTED 20120423
AGENCY: IA0520200 IOWA CITY Pb
CHARGE NO- O1 IA STATUTE IA700.2A(2)(A)
DOMESTIC ABUSE ASSAULT
rw
TRK#: lAp0E5U01
c
COURT DISPOSITION"£$?3
AGENCY: IA052015J JOHNSON CO DISI COURT
[V
COUNT NO- 01 IA STATUTE- IA700.2A(2)(A)
DOMESTIC ABUSE ASSAULT
COURT CASE ID; 06521 SMSM089571
CHARGE CLASS: MISDEMEANOR CONVICTION
.._
C71
TRK#: 1A00E5U01
-�
SENTENCE DISD EFF AAT
DEFERRED JUDGEMENT $65 CIVIL PENALTY 20120730
PROBATION lY 20120730
COMMUNITY SERVICE 30H 20120730
FINE $500 20121210
REVOKED 20121210
AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT. THIS RECORD
MAINTAINED BY THE IOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF
IDENTIFICATION I5,A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW
ENFORCEMENT AGENCIES BY THE DCI.
IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS
�N+
BASED ON INFORMATION FURNISHED, WE CANNOT CONFIRM OR DENY THAT THE RECORD
COVERS THE SUBJECT OF YOUR INQUIRY.
DIVISION OF CRIMINAL INVESTIGATION