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Home My WebLink About16-156I r I ��r ® III Xat� + �®6�Il .W�_ CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (3 19) 356-SO40 (319) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) IDENTIFICATION NO. I (� - (S - (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 3. Contact Information (REQUIRED) Email: 4a. Driver's License expiration date (REQI b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pa Middle Last 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? —47 Type of offense Where When ;s What happened to the charge? (Circle one) -� Convicted Dismissed Deferred Suspended Plead Gu11ilty��.,_Qthe� 7. Have you been arrested/ charged with any traffic offenses in the last five years? AA0V Type of offense Where 7 When — .0 3 J2 kILKo I LA . What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspende Plea Gu1��lty_t43er 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? -A,/ 7 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 c rtify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number issued on vlbexpiring on Dol �j. 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 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by Gg'v\!R rte\ v„lo:4 . MoIrAM n this �� day of f4:Fi;F#tri*,Fi*###Rx*x#x#x#x*xxxxx#xxxxxxxx}#xxxxx#xxxRxxxzxx#x#x##xx####*x#####fWWW#*WWkkMWWWiWWW*A'A"M*WW*,Y##kxfrA#*#*:F>Y�FRxxf*inix*hxx*k*Ai�xx#x*xxxxx 475 .F I have reviewed this application, DCI report, and the State certified driving record of this applicant anj hang 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 Cof Iowa City (Title 5, Chapter 2, City Code). i 3 Expiration da e o Dr' er's license i l Signatgre o.V 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. Sre of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update /, _A1 Date Clew IDRmaoocrr+Par92014amended.Doc 0712016 Cd"14 4JIOWADOT SMARTER I SIMPLER I CUSTOMER DRIVEN WWW.iowadot.g®v Office of Driver Services PO Box 9204 1 Des Moines, IA 50306-9264 Phone: 515-244-9124 1800-532-11211 Fax: 515-239-1837 www.towadot gov Inquiry Date: Customer Name: Address: 8/18/2016 GYIItS*FA3 Certified Abstract of Driving Record DL/ID #: 684AJ7013 (IA) CDL Permit Class: None Class: D Mohamed, Gamerelanbia Audit #: Ismail 2608 BARTELT RD APT Issue Date: 2D City/State: IOWA CITY, IA Convictions 1239348 08/18/2016 Expiration 01/01/2018 Date: Endorsements: 3 Restrictions: NONE Restriction None Supplement: History Information CDL Permit Issue None Date: CDL Permit 522462730 Mailing 2608 BARTELT RD APT Address: 2D Mailing IOWA CITY, IA City/State: 522462730 Date of 1/1/1957 Birth: None Sex: M Convictions 1239348 08/18/2016 Expiration 01/01/2018 Date: Endorsements: 3 Restrictions: NONE Restriction None Supplement: History Information CDL Permit Issue None Date: CDL Permit None Expiration Date: CDL Status: CDL Permit None Endorsements: ELG CDL Permit None Restrictions: !Johnson ID Status: None DL Status: VAL ACD CDL Status: None JUR CDL Permit ELG 03/24/2014 Status: Fail to Yield Right of Way !Johnson IA 09/20/2015 r�3 CDL Cert Status: None r=' !Johnson 'IA r� CDL Med Status: N&he Y "^r a,y =g Citation Date Conviction Date ACD Explanation M County. JUR 03/01/2014 Office of Driver Services 03/24/2014 iN01 Fail to Yield Right of Way !Johnson IA 09/20/2015 110/22/2015 ''M14 _ ',Fail to Obey Traffic Sign/Signal !Johnson 'IA Name: Mohamed, Gamerelanbia Ismail DL/ID: 684AJ7013 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: IOWA �s� 8/18/2016 D. 0. T.: Q�ida.J�p 12��iC ' v f BRIYFa Office of Driver Services State of Iowa Division of Criminal Investigation 215 E. 7"' Street Des Moines, Iowa 50319 Phone: 515/725-6066 Fax: 515/725-6080 Iowa Criminal history Record Check Waltz -In RPtvnPCf Your name; Address: s - City/State/Zi Phone #: Requesting an Iowa criminal history record check on: Fill in all shaded areas. Last Name aPelltdo (mandatory) First Name Primer Nombre (mandatory) Middle Name Segund" Nanbre (recommended) j Date of Birth PechaNacLmettm (mandator') Gender Generu (mandatnN) Social Security Number (rew.,, w=ded) o i A I h � s"� ❑ Male ❑ Female 411 Z0,0 Waiver Signature Flrma (If the request is on yourselt, please sten. if the request is on someone else. write NiA I Results As of a name and date of birth check revealed KNo record found ❑ Record attached DCI # DO initials Receipt Number of requests x S 15.00 per last name = Total amount $ Method of payment: cash money order Cardholder's name DCI initials Credit Card # DCI -83 (09/09/10; Revised 10/ 1/10, form reviewed 08/11/14) DO OSC nNI.t' 1) p..,.. check # Nlas(erCard or Visa (Last 4 digit,) �Y Exp. Date