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CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
L.osT
IDENTIFICATION NO.
(Office Use Only)
)� — 1(p%
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 complefe the "reouired" information will result in denial of the application
3. Contact Information (REQUIRED) Email: 5Ar,b7na 4jrn;r,.A. (,,),,vl Cell Phone: 311.-95-9 41 71
(All written communication sent via email)
4a. Chauffeur's License expiration date
b. Taxicab Business Name (REQUIRE[
5. Prior experience in transportation ofa,enye s: vt Y eo r >
N
0
6. Have you ever been arrested/ charged with any misdemeanors andlor felonies in this State or i;lsewhene?
Ttlleofoffense Where
Ln
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other -
7. Have you been arrested / charged with any traffic offenses in the last five years? A) 6
MT1 nse CWhere A r4 Whennrr
-ten
Whathappened to the charge? (Circle ono)
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? tin
Type of offense Wh Vdjeno
t„
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please s prov�Ule ni e
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DEPARTMENT OF NAL
NVESTIGATION
DRIVING RECORD MUST ACCOIMPANY THIS APPLICATION FOR POREPORT AND LICE CHTATE IEF 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 a fy that I have issued to me by the Iowa Department of Transportation v lid Chauffeurs license number
2� issued on o i 1 expiring on 1 2� I I understand that 'rf 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 applic ti n, and I further agree that, 9 authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions (T I r, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant) Date cq
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by W ^ M zo o� on this day of
do r
N ry Pu is in and for thib Sta e
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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 �q 1 l 1120 1(0
Signatu o Po'ce Chief or designee Date <� u
-17
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.
))WAi raz A/- " dee
S gna a of City Clerk or des
�te
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Approved application
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Office Use Only
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Approved application
DCI report
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State certified driving record
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Website update
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SMANER I SIMPLER I CUSTOMER DRIVEU - _
Inquiry Date: 8/4/2015
Name: Mohammed, Ahmed Musa
Address: 1147 WINCHESTER LN
City/State: NORTH LIBERTY, IA
523179162
Mailing Address: 1147 WINCHESTER LN
Mailing City/State: NORTH LIBERTY, IA
523179162
Convictions
office of Driver services
PO Boz 92041 Des Maines- IA 50306-9274
Phone: 515-244-9224 1800-532-1121 1 Fax: 515-239-1837
www.kiwadot.gov
Certified Abstract of Driving Record
DL/ID #:
51SAG3626 (IA)
Customer #:
5827626
Class:
D
ID Status:
None
Audit #:
9229982
OL Status:
VAL
Issue Date:
07/07/2015
CDL Status:
VAL
Expiration Date:
09/11/2015
CDL Cert Status:
Non -Excepted Intrastate
Endorsements:
3
CDL Med Status:
None
Restrictions:
Commercial Learner Permit,
Restriction
CDL Instruction Permit
CDL Intrastate Only
Supplement:
Expires 1/7/2016
Date of Dlrth:
9/11/1966
Sex:
M
History Information
Citation Date
conviction Date
:.CD
Erplanation
County
3UR
11/05/2011
11/30/2011
X03/18/2015
.592
_Speed
]ohn:on
lA
11/09/2014
_ _
�M14
Fail to Obey Traffic Sign/Signal
Johnson
IA ,
11/09/2014
03/18/2015
E55
Driving Without Headlamps or With Park Lamps
Johnson
IA
Name: Mohammed, Ahmed Musa DL/ID: 519AG3626
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, 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:
Name: Mohammed, Ahmed Musa DL/ID: 519AG3626
8/4/2015
c4m_ a4OF4=4
Office Of Driver Services
Iowa Department of Transportation
FrJu .-29. 2015, 9;05AMCIa Div of Criminal -----
Investigation o�,zsrzo,e,a,Nc. 1889K 1/2`rooz
STATE, OF IOWA
Criminal History Rectlyd check
is
Request Form
TO: lova Dd'ision of Criminal lnvestiga(iun
3uppm't Operstione Bureau, (" Floor-
215
loor215 L. 7" Street
DesMaines,loe'a 50314)
(515)725-6066
(515)725.6000 Fait
I a111 feetle5tin0 en )pwa Criminal 14inln,v RPrnrd rk.Aa nn,
DCI Accomu number -__ Ysd2�t _
iit+pplfenhlc) •�
Prom= _ City utlowa ell
City Clerk's Office
416 lt, wasbington Street ^--_-�-
lona Clly, lA 52240
Phone: 3MMSO41 _
Paz: 319-356-5497
Last Name (msnaao�9 _��
rst Name ts,+nalI:to
1tliddle Name ovc =undcd)
h�►��/tp)vsrl W` f�I,1v✓if�l �{l1SGl
Date of Birth imodalcg7 Gender (mmazm`y) Social SecurAt3 Number rpa as mam)
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LyNlale ❑frenrate
waiverlirforlflafiorr: Without a signed waiver from the subject of the request, a complete criminal histary record may not
bereleasable, per Coda of low•a, Chapter 692.2. For complete triminal history record information, as allowed by law, always
obtain a waiver si nature from the subject of din request.
1lraiVel%:E1CRSe:l hcrtDy give ppmissim fame b ve regyi �slinr orfieiel io conJun onlaga crlmh7at hi7loryfetard d¢d: ,yiill tYd Uivisian olCrbduai
lnvenig+tion(t)Cq. MY criminal hislorydfla tan¢ni p eik
llalaiaed'hyiLe DCi m+ybc refe¢mdu+lioivcd aylnrv.
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Received Time Jul. 28. 2015 2;20PM No. 1833
Iowa Criminal History Record Check Results
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As of
j -2q—a_, a search of the provided name and dale of birth revealgd;
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No lona Criminal History Record found wiill D(:1
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-
Iowa Criminal History Record attached, DU 11
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Received Time Jul. 28. 2015 2;20PM No. 1833