HomeMy WebLinkAbout16-147IDENTIFICATION NO, _ G _A P.
i (Office Use Only)
CITY OF'®VV 1"ITY APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
{Police Department review must be made between 8 a.m. to 3 p.m., Monday - F=riday)
410 East Washington strEel
Iowa Cily. Iowa 52240-1826 Failure to complete the "reouirect" information will result in denial of the application
(319) 356-5040
(319) 356-5497 FAX
1.
First
Name (REQUIRED) /t/j�61 Q (
qr, Middle
AOD CI_ MAdi FL
Last 1
4- RM-Eim 1
2.
Address (REQUIRED) -4- p 1Dey
c,
3,
Contact Information (REQUIRED) Email. 0c)1C
(Yl 2
Cell Phone. 3 Jet 5 4 22 C (>
(All written communication sent via
email)
4a.
Chauffeur's License expiration date (REQUIRED)
i
Z p
b.
Taxicab Business Name (REQUIRED)
5,
Prior experience in transportation of passengers:
\
r e , q ,
6. Have you ever been arrested 1 charged with any misdemeanors and/or felonies in this State or elsewhere?_
Tvpe of offense AAtr.,,.,, ,..,
What happened to the charge? (Circle one)
Convicted Dismissed Deferred SuspendedPlead Guilty Other I
Have you been arrested / charged with any traffic offenses in the last five years? \ Ai _
Type of offense
Where
When
C� -;,Li /Z_C�
What happened to the charge? (Circle one) F —Y
Convicted Dismissed Deferred Suspended lead Guily Othe
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? i"?
Type of offense Where When
7 t
( 9
r4.7
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide ft names)
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
issued on 2texpiring ony (� (7 , '7o 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
STATE OF IOWA )
COUNTY OF JOHNSON ) m
nn ,,,, ',11 11 �� ll
Subscribed and sworn to before me by,y l g n cQ 4 A-.�vl . i`t I t on this6 z day of
TLA_L- _Q Z e t_ _V i
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 O (§ Q 202 r)
Signature (Police chief or designee
EL2Zgt (,0
Date
AFTERAPPROVAL 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.
Signalufe of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Cierra>cloRivenoce PPL92014amended.DOC 0312015
uo.I4 2016 4�21F'M Uiv of Criminal invesfigation No. 6296 P. 2i2
•F�p rvi:olly of lawn ql[y CI9/k OfrICe 319 36664�Y OG/OF3 /;q Gee 1Sf !i e. µ64O P.002/002
STATE OF 10WA
Cwm n -final History/ Remrd Check
l @I Request Form
9'u: Iowa Divisinn of Criminal 111ves0gatim
Support Opel afiotrs Bureau, 15' MOOT
215 C. ?"Street
Ns Moines, IOwn 50319
(1515) 726-6066
(515)'725-6080 Y'ax
ant requesting an Iowa Criiiiinal
Last Na le (ni ndolor))
Date of Birth onnndalpq
on;
M .A G D i
DC1 Accounl Tluntber: _ yC:)D --Z—
TO:
Z
Frain; City of Iowa City_
City Clerk's Dfflce.----
410 E.'Wasitiukton�trect
Iowa ON. IA 52240
Phone: 319-356-5041
Fax. 319-356-5497
�A4ale Female
���cLf� �c>1�Ep MoNAf��L
f1valver 1Ltjormaffort: Without a signed waiver from the subject of the request, a complete ediniaal history record may out
be releasable, per Cade of Iows, Chapter 692.2. r''or complete criminal history retard information, as allowed by law, always
obtain a waiver signature from the subject of the reauest.
Waiver Release: I Ircreby aivc pcow"ion fo.g Asur€,6,ltloofficialtomnduom to»re criminal hiaiii), ecoid check with the Division ofCrimuaal
IDeesligatiou (DCII, Nry criroiusl history data con en,iu�g-^mle Jlzl mai it ed by mcUCt may he rdeased as allowed by law.
Waiver ,Siplaft re;_ c / `�Q-o-4Q,
Iowa Criminal History Record Check Results (nCllist Only)
As of v`(�7� a search of thee provided name altd date of birth revealed: r=
No 10Wa Ctilniltal History Record found with DCI
�I
❑ Iowa Criminal History Record attached, DOl #
J�j N
DClinitials !9 �
Received Time Jun. 6. 9016 4!01PM No- M7
WPA00T
-- www,ioWadot.gov
SMARTER I SIMPLER I COSTUMER 6RIUEN._......,�.
Office of Driver Services
PO Box 9204 I Des Moines, IA 50306-9204
Frei 515-244-9124 1 800-532-1121 I Fax: 515-239-1837
www.iowadct.gov
Certified Abstract of Driving Record
Inquiry Date:
6/28/2016
DL/ID #:
463AF2313 (IA)
CDL Permit Class:
None
Customer #:
5747667
Class:
D
CDL Permit Issue
None
Date:
Name;
Ali, Magdl Abdelmageed
Audit #:
9103552
CDL Permit
None
Mohamed
Expiration Date:
Address:
1637 ABER AVE APT 8
Issue Date:
05/21/2015
CDL Permit
None
Endorsements:
Expiration Date:
01/01/2020
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522464729
Endorsements:
3
ID Status:
None
Mailing
1637 ABER AVE APT 8
Restrictions:
NONE
DL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522464729
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
1/1/1980
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
37/14/201208/16/2012
Office of Driver Services
592
.Speed
Johnson
]A
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number IUR
12/18/2012 717412 IA
04/30/2016 918607 IA
Name; Ali, Magdi Abdelmageed Mohamed DL/ID; 463AF2313
Pursuant to Iowa Cade §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
I.— _.••;,v/'4i
6/28/2016
IOWA `?''s
D. 0. T.::�
r, �
Pf "••"i�S�
Office of Driver Services
Iowa Department of Transportation
Name: Ali, Magdi Abdelmageed Mohamed DL/ID: 463AF2313