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Home My WebLink About16-116r CITY OF IOWA CITY 410 East Washington Street C-1 ��52240-1826 (ST9t-336-504 ,� (319) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) IDENTIFICATION NO. (Office Llse 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) Failure to complete the "required" information will result in denial of the application First Last 3. Contact Information REQUIRED Email fit' " (REQUIRED) 1,F enco1 un �/� eG•CellPhone:'�j3 (All written communicationent wa email) 4a. Chauffeur's License expiration date (REQUIRED) i1 i e n t i i g 2 A b. Taxicab Business Name (REQUIRED) _ ( j tz 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When A 1 r3 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? Tc.s Type of offense Where When f'i ,. n(itf, J141 /o(vt t.fw Do doio I&Z� 5-Wr�&4 SAF 0, - _� F What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended PI ad Gull Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the las five years? Type of offense Where When h1 D 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) 110 DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REV�,4W 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 I hereby certify, that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number at � j R issued on A�IniiA expiring on )) rot iu 2�' 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 Applicant Date 6/ f / /E STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by Q)0 I cc, 41 q , p _jt �,�, "9 on this _ day of Tk L.. -(L Zot _k , . for the State)bf Iowa 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 01 � b + I Z D Z O _111R3 Signature 6f Police Chief or designee t>Co17i(n 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. Signature of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update ate ClerkrrAXIDRIVBADGP PPL92014amended.DOC 03/2015 WWADOT VwAvio a 0t.g v s,"iF FTE i? 3 l r: !tJSTt3'')EF [i!?!' — Office of Driver Services PO Box 99204 i Coes Moines, I.A 5U306-3204 Phone: 515-244-4124 1:800-53?- 1121 1Fax- 51 t'239-1937 s A''-tawauot.gtiv History Information Convictions Citation tante Conviction Date ACD Explanation Couno, lug 04/09/2016 05/09/2016 N63 Driving Wrong Way on one Way Street Johnson IA Name: Mohamed, Noureldin Adam Osman DL/ID: 913AL1908 Pursuant to Iowa Code 5321.10, 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: Certified Abstract of Driving Record Inquiry 5/8/2016 DL/ID #: 913AL1908 (IA) CDL Permit Class: None Date: Office of Driver Services w8—� Iowa Department of Transportation GPt Customer 6314142 Class: D CDL Permit Issue None #: Date: Name: Mohamed, Noureldin Audit #: 9156279 CDL Permit None Adam Osman Expiration Date: Address: 2530 BARTELT RD APT Issue Date: 06/10/2015 CDL Permit None 2C Endorsements: Expiration 01/01/2020 CDL Permit None Date: Restrictions: City/State: IOWA CITY, IA Endorsements: 3 ID Status: None 522462719 Mailing 2530 BARTELT RD APT Restrictions: NONE DL Status: VAL Address: 2C Restriction None CDL Status: None Mailing IOWA CITY, IA Supplement: CDL Permit ELG City/State: 522462719 Status: Date of 1/1/1972 CDL Cert Status: None Birth: Sex: M CDL Med Status: None History Information Convictions Citation tante Conviction Date ACD Explanation Couno, lug 04/09/2016 05/09/2016 N63 Driving Wrong Way on one Way Street Johnson IA Name: Mohamed, Noureldin Adam Osman DL/ID: 913AL1908 Pursuant to Iowa Code 5321.10, 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: �ENICIf 14", 6/8/2016 10 ...... S_ ` hio Office of Driver Services w8—� Iowa Department of Transportation GPt Peiun i6 2016 3:28PM Div of Criminal lnvestigation No. 6502 --;-. STATE OF 101YVA F , . Criminal History Record Check Request Form To: Iowa DbA lon of Criminal Investigation Support operatldns Bureau, 1" Floor 215 r. i"' Street DES Molues,10WA 50319 (515) 725-6066 (5!5)725-6080 Fax 1 am requestiuk all Record Male on: DCI Account Number; L4 uq Z jif epplicnblc) Frons Citv oflowa City City Clerk's !-thee 410 r. , bht on Street Iowa City, IA 52240 Phone: 319-3$6-5041 Fax; 319-356.5497 OFeniale Waiver' hYfOrmatiofl: Without a signed waiver k0o) the subject ofthe request, a complete eriminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as sllo%ved by law, ahvays obtAitt a waiver sIvrmtnre rrnm ihn. en6F,..i . r H.. r......_-. Walver Release: I hereby give Permission for the about rcgacsing official to conduct an Iowa criminnI history record check with the Division of Criminal Invcsigat ion (mCt. Any criminal hislory data concerning me that is maintained by the t)C1 rosy be released as allowed by law, 1folver Signatlrl'e: Iowa :ck Results (I)CI ase only) As of (gll6hk a search of the provided name and date of birth revealed';:j M r c C r Ct No Iowa Criminal History Record found with DCX !.. ® lows Criminal History Rocord attached, DCl # .. DClialitials _ = DC147 (08/25/10) -- Received Time Jun. 13. 2016 4:05PM No. 465