HomeMy WebLinkAbout16-131IDENTIFICATION NO. ) � — IISI
(Office Use Only)
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1
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
410 East Washington Street
Iowa City. Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application
(3 19) 356-5040
(319) 356-5497 FAX
First Middle Last
1 Name (REQUIRED) i tolNuy» PC1 S 0-S --2.7,1
2. Address (REQUIRED) 392 9,-1 on • Lctnr Ij, Iag evJ 64y -L c1G
3. Contact Information (REQUIRED) Email. M-Mdlajcy b C 9,. 'w —Com Cell Phone:
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) O 3 / 11 1 2022
Id. Taxicab Business Name (REQUIRED) _ Aw elr j (ri h q << a
5, Prior experience in transportation of passengers:
& Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? A10
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other Al b
7. Have you been arrested / charged with any traffic offenses in the last five years?
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? NO
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)
Nd
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
c) q 2 q L Sba $ issued on expiring on o 3 / ill 2-oL!1- . 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)
fJ� b�lch�2e!%
Signature of Applicant �" _ Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Vn"AA`QZ 1S DSd-lcz,,, on this _ day of
I have reviewed this application, DCI report, and the
there is no information which would indicate that the
dents of the City of Iowa City (Title 5, Chapter 2, City
record of this applicant and have determined that
trimental to the safety, health or welfare of resi-
/[ Z Z
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.
Signare of City Clerk or designee
Approved application
DCI report
State certified driving record
Website update
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STATE OF IOWA
Crrimialal History Recard Check
10111
' Request Forrm
T w Iowa Divis(an of Criminal Investigation
`yUppurt Operations Bureau, 1" Floor
215 C. 71h street
Des h7oines, Iowa 50319
(313)725-6066
(513)725.6090 Fax
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17C1AccountNumbec l�/of"��
(irayplicable)
From; _Clty of Iowa ON _
City Clerk's Office
47.01;, WashUt !on 5trect
-Iowa City, IA 52240
I'hone: 319-356.5041
Fax: 319.356-5x97
Last Name (nandamry)
First Nalne (mandatog)
ame (momn,endedi
oftrae-)
fV)pi-,4 r,17ecl
•
Date of Hirth (mandatory)
Gender (mandatny)
eeuri ' Number (recommended)o3J1r
/1q&P
S'/`��aVer
tallowed
rtlfomzafio1lf without a signed Nyalvcr from the subject of the request, A Miminal history record may notbe
releasable, per Code of Iowa, Chapter 692.2. Forcortlplete criminal history recordion, as allowed by law, always01)(Mu a waiver xi nature from the snb ect of the re uest.
N,'aiver Reieas& 1Hereby give ptrmission forthe abo,'cmquesdngoM6al w conductan Io\I'acriminal hithen{ wid, lot Ui,•i5ion of CriminalAny enrninal hislory data eonecfning me tLatis mainlailmd by the DCI may be released as aW,
l'i�afVCr Siboryftl7tYC: '�1J LA) LIL
Iowa Criminal Histon, Record Check Results (UCl nau tnly>
As of m _ 0,2' a search of the provided name and date of bhth revealed:
135- No Iowa Crilni,gal History Record found with DCI
•'i r;
r...a
❑ IOWa Criminal History Record attached, DCI # v:
DCI inilials-6v— �y
v
al J -(f 1VoIzNw)
Receivtd Time Jun 24. 2016 1:53PM Ro-6272
4 DOT
T R I SIMPLER I CUSTOMER DRIVEN V1iWVV.lOWc�iOt.�DV
SMARTER
Office of Driver Services
PO Box 9204 l Des Moines, IA 50306-9204
Phone: 515-244-91241800-532-1121 1 Fax: 515-239-1837
www.iowadot.gov
Certified Abstract of Driving Record
Inquiry Date:
6/23/2016
DL/ID #:
942AL5605 (IA)
Customer #:
6409705
Class:
D
Name:
Usman, Mohamed Sharaf
Audit #:
9516039
ID Status:
Mahjoob
DL Status:
VAL
Address:
342 FINKBINE LN APT 11
Issue Date:
10/22/201.5
Expiration Date:
03/11/2022
City/State:
IOWA CITY, IA 522461714
Endorsements:
3
Mailing
342 FINKBINE LN APT 11
Restrictions:
NONE
Address:
Restriction
None
Mailing IOWA CITY, IA 522461714 Supplement
City/State:
Date of Birth: 3/11/1981
Sex: M
History Information
CLEAR DRIVING RECORD
Name: Osman, Mohamed Sharaf Mahjoob DL/ID: 942AL5605
CDL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
. lyJ o
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
Iowa Department of Transportation
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status: None
CDL Med Status: None
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, Director of Oftec of Driver Services, Iowa Department of Transportation, do hereby certify that I ar
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 c
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:
b; •"'••.:;!j4t
.IOWA
6/23/2016
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Office of Driver Services
Iowa Department of Transportation
Name: Osman, Mohamed Sharaf Mahjoob DL/ID: 942AL5605