HomeMy WebLinkAbout16-144IDENTIFICATION NO_ j qq
i l i (Office Use Only)
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APPLICATION FOR TAXICAB I 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 Cast Washington Street
lona City, Iowa 52240-1 626 Eailwe to conv�alete the '7equit'cd" inlonnatlon will resultin clenia) of tht epplic-aeion
(319) 356-5040
{319) 356-5497 FAX _
First C \ � + �/'
C Middle q! Last
1. Name (RLOUIRCU)}ti^ c-\..__/Ui
2. Address(.P-QUIRFU) 5 _1 py.J c— 4 !
3. Contact Information (REO,UII;ED) EmaiP �� t tNl� EelPh ne:
'All written communication sent 'a email) p )
4a. Chauffeur's License expiration date (RLOUIRLD) c3
b. Taxicab Business Name (REOUIREDI
5. Prior experience in transportation of passengers_
6. Have you ever been arrested/ charged with any misdemeanors andfor felonies in this Slate or elsewhere? � S
Tvpe of offense Where 'Nhen
What happened to the charge? (Circle one)
Convicted{ Dismissed J Deferred Suspended Plead G IIty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Ty/p�e of offense Where When
What happened to the charge? (Circle one)
_N
Convicted Dismissed Deferred Suspended Plead Guilty ::;Other_
0
8- Has your driver's license or chauffeur's license beer suspended or revoked in the last five
Type of offense Where
r`J
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prdGide the riame(s)
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCij 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
I hereby certify that I have issued to me by the Iowa Department of Transportation n va'.id Chauffeur's license number
ch c� issued on O' _ e i I expiring on ca _c c r _'Lei f 31 understand that if I
falsely answer any que�ons ir�t�is application, that this application may be denied. I agree that in making this applieatron, I
consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to exarnlre any and all records and
documents relating to this application, and I f urth agree that, if authorisation to be a taxicab driver is granted, to comply at all
times with all of the provisions of Title 5, Chapter 2�Qf the City Code. (Needs to be signed In front of a Notary Public)
Signature of Applicant Date /d
f:xi-**3-F3=it,*»*'�Sfl,1-k*Rt*k*T*=siirt*lfeX*3,*3*xfxx,xi*sk1'x*=f[fr*33x1.3x3x3FYx#Fwxix%kk, *,**=3**kk3Mk,Yk.:F*NR,*kik,*x«3*kkkkl*ea'*****xi*x**xx*xifrt**
STATE OF IOWA )
COUNTYOFJOHNSON )
C �
Subscribed and sworn to before me by r pec\J ;+ 1� S a1 on this day of
*h»xxiY*3**k**xx:MHxx3x3xxxxxx3xkxxRxx Yi3YHxxxxxxf:xxx**xxik SRYYixxkk*k*kxx****k****t*3*k**S*R***H*kkHa****k***:11*3kkkH*x*kkikkk*x3*kkx*MRxk
I have reviewed this application, DCI report, anu the State certifed 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 welfnre of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
/da of �ExpirarilIeur's license
Signal !re of PoW v ief or designee Ducat
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.
&gnatim of City Cleric or designee
Dater
*«*}*YSki*kM4rt#'.MxT£*ttt'kFtRRTIKRklrkt*5=k*k*:Fk**XR:t*k==k:FR*=====*t**=k*ki*k1:xw.=Y3«e««3*f-.FxxY3333YY.x3+x3xs Rxif*iixx=3x=3,===kk=,.k xx Ykikiki#*x
Office Use Only
Approved a licationk
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DCI report
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State certified driving record
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Website update
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aakrrwciowvenoc�r��eaoi4amenaea W c
03/2015
20150:45AM Div of Cardinal Invaet rat on No. 8210 P. 1/1
•v�.- —.y clan. — r._, —, 10/0712016 14:,., J2.a -,--2/GG2
STATE OF 11DWA
Criminal History Reccfl•d
Request }jai -m
DCJA.ccomwNwnber; L(C�a, -F
fif epplicxLkj --
To� 7o)v9 DivlNoe of Criminal Tnvestlga fi on from: Cit) of Inwfl Cic�t
Suppnrt Operations 6areau, I,' Mai Cit4 Clerk's C IGre ^
z15 E. 7"' Direct 410 E. 6)v'msbingtml 5u'ec[
Des Moines, Iowa 60319
(515) 7256066 beta Com,. 1A 51240
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1. am rcque3ting an 10l�'A C imiaa l
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Phooey 319-356.5041
rex: 319.356.5597
Record Check m1:
Mist fdama (ma,
ckt 1,(V\ e ` U 4 V,\
®]Male Ohefnele
5'ocial Secrtri_. ty� tuber ttxommmdedj
C2
Waive), lfIfor'F1llllioftl 'millout a signed waiver from fhasubject of the regrow, a complete ori,n h)al history record may not
be rereasablc, per rude of Iowa, Chapter 692,2. For complete criminal history record lufarnlaliou, as allowed by law, ahaays
obtain a.Maiyersiknature. from [he s,blect of the .•un,�,.�t
Waiver Relen5e:lggCUyervcPC. Ilk. 3511111fDluieaaovc(cgceslill goflitill to nducleglo,4aGimi1511ri510 rGpldchC:
bwoylgalinn(DGf}. Mry tria)ilmlhimdp'dalacon"n);g M. 11,011, maihiaiaed by the hm0y 6e talear:d of 01105 ed by law kwith the Division olCrin11na1
Waiver Signature:
Iowa Criminal Histol r i�eca d Checlr I2esolt
lcc, p£C Dtltyl
As of ]� a search of the provided nauae and date of hirlh revealed:-,: —
No Iowa Criminal Hisletry Record fowid with DG � f
lma�a Crilniaal history Record attached, DQ 4 = G c7
1 iV
DC1 initials _. III
Received Tlme Oct. 7. 2011, 2:'Wh No. 969?
a
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Vw.'LV.low aClOt,iQV
Office or Driver Services
PO 5o1 5204 DPS Mrnnoi. 1.4 50"s0F-5204
✓bz^c: 515--44-5124 !. `u:}F3`- ?: 1 I F3a: 515.235-183;
W W4 Iow�loi.goi,
Certified Abstract of Driving Record
Inquiry Date:
10/7/2015
Dll all
137BB0959 (IA)
Customer *i
4102089
Class:
D
Name:
Salim, Nagmeldin Mohamed
Audit 4r:
5175614
Address:
2548 INDIGO DR
Issue Date:
0810112012
Expiration Date: 06/04/2017
City/State: IOWA CIN, IA 522406808 Endorsements: 3
Mailing
2548 INDIGO DR
Restrictions: NONE
Address:
CDL Permit
Restriction None
Mailing
IOWA CITY, IA 512 4 06 6 0 8
Supplement:
City/State:
Restrictions:
IN
Date of Birth: 8/4/1967
None
Sea:
M
CDL Status:
History Information
Convictions
CDL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Explanation
CDL Permit
None
Endorsements:
07/26,111
COL Permit
None
Restrictions:
IN
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status: None
CDL Med Status: None
::tat:Oh Date
Conviction Date
ACD
Explanation
County
]UR
11/28/2010
07/26,111
592
Speed
IN
1711812014
07/25/2014
S93
Speed
Johnson
IA
Accidents - Accident involvement indicated does NOT mean the individual Was at fault or given a citation.
Occident Date Case Number
1012
77/1812014 808533 IA
Name: Salih, Na9meldin Mohamed DL/ID: 137BB0959
Pursuant to Iowa Code §321.10, I, Kim Snook, 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, -.tat this I5 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, 1 have caused my signature and the seal of the Department to to set upon this document, at Ankeny, Iowa this date:
h�tWGf y'vv�h�.�p
D.0.T..;
,117' Ito
Name: Si lih, Nagmeldin Mohamed DL/ID: 137BB0959
10/7/2015
l
Off Driver Services
4`:e�
Iowa Department of Transportation