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Home My WebLink About16-088� t 1 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO. 16— 0 (Office Use Only) APPLICATION FOR TAXICAB 1 MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) Failure to COMil the "required" information will result in denial of the application First Middle I? - 3. 3. Contact Information (REQUIRED) Email: Sbu1 �jc¢r�'9 Qi[ Cell Phone: �l$- Z1; SI �G All written comm nication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) / a / 2 9 b. Taxicab Business Name (REQUIRED) _ C i c!! re,.r 5. Prior experience in transportation of passengers: G � � yell- a 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? lVv Type of offense What happened to the charge? (Circle one) Where Convicted Dismissed Deferred Suspended Plead Guilty 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where When Other IL. -IA When What happened to the charge? (Circle one) m_ Convicted Dismissed Deferred Suspended Plead Guilty Other y"Nf/I 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 71i a Type of offense 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) 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) 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 - 6 ?;' A 10 -; 14 issued on e6t2 xpiring on 1-/28/ zo 1 q . 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 Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applican � Date - y/2 G/ 2-1G STATE OF IOWA ) COUNTYOFJOHNSON ) subscribed and sworn to before me by S .J 4� v • 3 M. S IDT 6kr— on this 'Di° 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 orwelfare of resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). Expiration date of Chauffeur's license �2-o1 '6 Signat e olice 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. / / la•2LC:7z!/ % . all Sign Lure of City Clerk or designee GA - ate Office Use Only 7 17 IV Approved application DCI report State certified driving record F5 Website update c Clerk MIDRN6lDGE PPL92014emended.DOC 0312015 F,Apr 21. 2016 2: 08FM�gr� Div or Crimina�lnevestioo atin oa/zo zone N�7� c,2503P.9/92/OO2 °wSTATE OF IOWA t�sOWa ,Request P011111 To: ln« a)3lvision of Critnlnal Investigation EBlpport Operation51 Ilrenu, l" Now 715 F, 7'h Sb cel DES MOINES, Iowa 50319 (515) 725-6066 (515)725-6080 Fax an 13u2gu)Q Date DCI Acconol X1111111,61: (if ypplicahle) —.�. From; City of lova Cit City Clerlf'S offrc�e~'�_— ---"-' 410 F,. lVeshinglou It, oet ioeva Cily, IA 51240 Phone: 319-356-5041 _ Fax: 319-356-5497 f�ll%�Hrl�l� � �UH��MED 1� Male ❑1!etnale I I S--/— 21- 2 ! J -G rf•atver• WOI'Fltf WIV Without a signed waiver from the subject of the request, a complele criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. rar c OMP let e crlminat history recnl'd in6rmatlon, as allowed by law, elnvays o0(a6r a waire_r signature from the subiecl of the request. Waiver Release: 1 hereby give permission for ole aoaFc rcqucslh)g official to conduct en )own c(ilniaul hlnory rceard check nvilh the Division of Criminal Invcsligalion(C7Cf). Any ttiminsl hisloq�dela......mingm�e, ,I, mmoimainedby the DCI maybe released as ellmvcd bylaw, rclordc i�fClver sCnnnlGl'/,G/ " Iowa Criminal History Record Check Results (I)CI ii& only) As of a search Of the Ivrovided name and date of birth revtaleti: 'l No IOwa Criminal History Record found with DC) M El _ lotma Criminal I-l.istory Record attached, 1)CJ q 1)Cl initials y 1)C l-77 (08/75n0) Received Time Apr.20. 2016 12:02PM No.2729 X41 DOT SNI; ATE€ I < WLE? i (G`T ',A I R"1 Office of Driver Services PO @oti 9204 1 Des Aro[neS. IA 503136--6244 Fiaaa-e: 515-244-95241 E32':21 i Fax 515-239-1237 + M'W.wvvaoot.gav Inquiry Date: 4/26/2016 Customer #: 6098518 Name: Burbur, Seedahmed Mohammed Sidahmed Address: 888 BOSTON WAY APT 6 Certified Abstract of Driving Record DL/ID #: 705A30514 (IA) Class: D Audit #: 7084480 Issue Date: 06/28/2013 Expiration Date: 10/28/2018 City/State: CORALVILLE, IA 522413126 Endorsements: 3 Mailing 888 BOSTON WAY APT 6 Restrictions: Corrective Lenses Address: Restriction None Mailing CORALVILLE, IA 522413126 Supplement: City/state: Iowa Department of Transportation Date of Birth: 10/28/1976 Sex: M History Information Convictions CDL Permit Class: CDL Permit Issue Date: CDL Permit Expiration Date: CDL Permit Endorsements: CDL Permit Restrictions: ID Status: DL Status: CDL Status: CDL Permit Status: CDL Cert Status: CDL Med Status: None None None None None VAL VAL None ELG None None Citation Date Conviction Date ACD .�-xpianation County JUF- 11/23/2013 107/02/2014 M14 Fail to Obey Traffic Sign/Signal 3ohnson 'IA Name: Burbur, Seedahmed Mohammed Sidahmed DL/ID: 705A30514 Pursuant to Iowa Code §321.10, I, Melissa Spiegel, 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: ?: •""••:v4i/%prr . 4/26/2016 IOWA � . Bq.....SE Office of Driver Services Iowa Department of Transportation Name: Burbur, Seedahmed Mohammed Sidahmed DL/ID: 705A30514