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Home My WebLink About16-134r 1 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 3S6-5040 (319) 356-5497 FAX IDENTIFICATION NO 1C - ►34 (Office Use Only) APPLICATION FOR TAXICAB / 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 lMiddle Last 1. Name (REQUIRED) EC/ / ,q r1lP {� 2. Address (REQUIRED) ZJA 93£ �svf (—c�/ afti,ffp A 3. Contact Information (REQUIRED) Email: eIuya-l'ed 6q� gr6a it -&e Cell Phone: &/ {i- S22 (All written communicatf&h sent via email) 4a. Driver's License expiration date (REQUIRED) 01 — 01— 2011 b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: 7 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? /\/cL Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty' ..; .Other_ Have you been arrested / charged with any traffic offenses in the last five years? — NO —,0 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? Fes% p 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) 0712016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby�ertify that I have issued to me by the Iowa D partment of Transportation a valid Driver's license number SS S gK6 090 issued on o6 0f expiring on o o 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 2,1 L the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant Date - o/ STATE OF IOWA ) COUNTYOFJOHNSON ) 1 t -h SLILscribed and sworn to before me by �� y� �� a �� ssq m choM�� on this (^ day of " QY ublic in and for the State of Iowa 713 1 I'l #wfiWWwwwiw*wwxw*ww****wwwwiiw*w*ww}w}ww**w****Www}w**wwww*w**w****iwiiww*wwwwwwww<*w*#wwwww***#wwwwwaw*****wiwww+*ww}www�x*ww***wiii}wwwiwwww*** 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 Driver's license L A L Signature of Police 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. Signature of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update 7z2l,/ :;�Date Clerk/ IDRIVB DGEAPPL92014.m ded.DDC 07/2016 F,,dol.2D, Lu10„ J:Ioriwole.JIV C L,rInIna I InveSligalion IMHd( Y. 4 -- — — ------ 07/20/20le iz:,i 0587 H.002/002 ST'A'FF OF IOWA Criminal History Record Check Request Form TO: fotva D4'visiuo of Crhalnal lnvestigatien Support operations liurean,1L1 Flom 215 L, 7'h Street Des Moines, Iowa 50319 (515) 725-6066 (515) 725-6000 Fax Criminal mekW,e to of Birth �j/01 /l9'_�S" Check on: L LLVZle DCfAccount Nlunber: (if applicable) From; City of Iowa Cita Cdty Clerlt's office ��- 410 C. Washil Bion 9freet tows City, IA 51240 Phone! 319-356-5041 Fax, 319-396-5497 tldMale 17IFcmale / a/ sa SD3-6(7-2gGq W(ri1,e14 Xnfortntafioti. Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Cade of Iowa, Chapter 692.2. For complete crimhtal history record information, as allowed by law, always obtain a Waiver signature from the suhiect orthe rnnikca Wrl;ver Release! I hrreby p,irc PmAtsion for the ove requesting official to ConCuel an Iowa criminal histoTy record check wnh We Division of Criminal Im esligatl(n (or)), My criminal li,9,, dale wil"I'llIn m tbhl ie maintained by lbe nCl may be released as allorvcA bylaw. Waiver Siplelfure: k,.1 re,,. Llowa Criulinal HIStt)r Record Check Results (Dcl nn only) As of % �� a search of the provided name and date of birth revealed: No Iowa. Cr;,ninal T-Iistoty Record found with DCI - N i r. G , ❑ Iowa Criminal History Record attached, DCI4-7 41 � DCT initials o G DCI -77 (08/25/10) -- — Recd ved Time Jul. 20. 7016 2:03PM No. 8676 DOT �- wwWJowadot.gov SMARTER I SIMPLER I CUSTOMER DRIVEN...... Office of Driver Services PO Box 9204 1 Des Moines. IA 50306-9204 Phone: 515-244-91241800-532-11211 Fax: 51fr239-1837 www.io,vadot.gov Inquiry Date: 7/26/2016 Customer #: 6231198 Name: Address City/State: Mailing Address: Mailing City/State: Date of Birth: Sex: Mohamed, Elwaleed Mussa 106 1ST AVE Certified Abstract of Driving Record DL/ID #: 815AK6090 (IA) Class: D Audit #: 9192893 Issue Date: 06/23/2D15 Expiration Date: 01/01/2019 CORALVILLE, IA 522412602 Endorsements: 3 1061ST AVE Restrictions: NONE Restriction None CORALVILLE, IA 522412602 Supplement: 1/1/1975 M History Information CLEAR DRIVING RECORD Name: Mohamed, Elwaleed Mussa DL/ID: 815AK6090 CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: CDL Permit None Endorsements: Office of Driver Services CDL Permit None Restrictions: 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 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: :......•••;��'Z 7/26/2016 IOWA D. O.T.�wy PP. U'**'ill o Office of Driver Services Iowa Department of Transportation Name: Mohamed, Elwaleed Mussa DL/ID: 815AK6090