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Home My WebLink About16-157� � d t.,k- JrY1 CITY OF IOWA CITY 410 f=ast Washington Strcet Iowa City, Iowa 52240-1826 (3 19) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO. ( Im — 15 j (Office Use Only) APPLICATION FOR TAXICAB 1 MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday- Friday) f asLLLI-elo CGit pt r—fi 14F _ p_es lq.F -@d inigrnf a F&t b7wFA`i dk.5 ti itlGk C}"eniat 0Me s'ffiCtz $iLtiC'F First 3. Contact Information (REQUIRED) Email: 4a. Driver's License expiration date (Ri b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pa Middle Last y.,.�„-7�f�,ln. d (tl'4vg hCellPhone: communication sent via emniifri i I ok & Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elseO.pre? � 7 Type of offense Where Wen QD What happened to the charge? (Circle one) -,U Convicted Dismissed Deferred Suspended Plead Guilty 01i 7. Have you been arrested / charged with any traffic offenses in the last five years?( Type of offense Where When f 31zN120+4 What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspende Plea _Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? a4`2 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) 07/2016 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 -� r) issued on Y expiring on 01 , QQ. I understand that if I falsely answer any questions in this application, that this application may be denied. I a ree 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% �. STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by G �Yn e. �� vti� a , f toVgVnon this day of -)_b l b (Nota rytblic in and forth State of wa 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 Com, of Iowa City (Title 5, Chapter 2, City Code). license � I I I ( d or designee r/�-/� 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. Signtrture of City Clerk or designee Date Office Use Only Approved application DCI report State certified driving record Website update CaerWrAXIDRN6ADGE PPL92014.me,d.d.Doc 0712016 C SMARTER 15IMPLER I CUSTOMER Inquiry Date: Customer Name: Address: 8/18/2016 6082673 Office of Driver Services PO Box 9204 1 Des Moines, IA 50306-9204 Phone: 51`x244-91241800-532-11211 fax: 51.`-239-1837 www_iowadot gov Certified Abstract of Driving Record DL/ID #: 684AJ7013 (IA) CDL Permit Class: None Class: D Mohamed, Gamerelanbla 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: 10/22/2015 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: Explanation CDL Permit None Endorsements: r..., NOl ¢+ CDL Permit None�.;y Restrictions: ' 10/22/2015 ID Status: .. None,-; DL DL Status: .. yA,=, CDL Status: None_,y CDL Permit ELG Status: CDL Cert Status: None CDL Med Status: None Citation Date .__— Conviction Date ACO Explanation County JUR 03/01/2014 03/24 _ NOl ;Fail to Yield Right of WaY _..... i,]ohnson '.IA /20/2/2014 09015 10/22/2015 M14 Fail to Obey Traffic Sign/Signal jlohnson 'IA Name: Mohamed, Gamerelanbia Ismail DL/ID: 684A77013 Pursuant to Iowa Code §321.30, 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 1 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 8/18/2016 D. 0. T. ij j yj,4 a OP.G?g� r Office of Driver Services State of Iowa Division of Criminal Investigation 215 F. 7" Street Des Moines, Iowa 50319 Phone: 515/725-6066 Fax: 515/725-6080 Iowa Criminal History Record Check Walk -In Request Your name: Address: �5 13�zlfilr��_-- Ci /State/Zip:� •�� r/y Phone #, . Requesting an Iowa criminal history record check on: Fill in all shaded areas. Last Name Apelwo (mandatory) First Name Ramo ,V omhre (mandatory) Middle Name Segund, N,mbre (recomnlended) �/. �yiY7��£'�`�• j Y ttq' T—Cfl Date of Birth FecbaNae mienlo tmandamryl Gender ce,ero (nandator) Social Security Number (remmnx ded) LE] Male El Female ,t Waiver Suture FirmaQf the request is on yourself, please sign. If tile regUCSI lion someone else, write N/A) Results DC1 UYF ONLY As of�} a name and date of birth check revealed: XN o record found t. ❑ Record attached DCI # - D('1 initials Receipt Number of requests x $15.00 per last name = Total amount $ Method of payment: cash money order _ check # MasterCard or Visa .. ......... '(Lasl 4 digits) Cardholder's name ' DCI initials -------------------------------------------------------------------------------------------------------------------------------------------- Credit Card # Exp. Date DCI -83 (09/09/10; Revised 10/1/10; form reviewed 08/11/14)