HomeMy WebLinkAbout16-173� r 1
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-SO40
(3191356-5497 FAX
1. Name (REQUIRED) _
IDENTIFICATION NO.
(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
f� Mo�iarn�{
First Middle Last ,9
2. Address (REQUIRED) 362
3. Contact Information (REQUIRED) Email:
4a. Driver's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers:
6. Have you ever been arrested /
I Vt.2_
with any misdemeanors and/or
What happened to the charge? (Circle one)
2V -
in this State or elsewhere?
Convicted Dismissed Deferred Suspended Plead Guilty
7. Have you been arrested / charged with any traffic offenses in the last five years?
Other
What happened to the charge? (Circle one)
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? _
Type of offense Where When
9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please provide the—„
NO -
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 certify that I have issued to me by the Iowa D pa ment of Transportati n valid Driver's license number
7%SZZ�SS32 issued on °SI o 2c/ expiring on o7m 20 I understand that if I
falsely answer any questions in this application, that this appli tion ay be denied. ag a 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 a O / b
A4L
STATE OF IOWA )
COUNTY OF JOHNSON ) 1
Subscribed and sworn to before me by 'rAr nt qLL., k n this S O day of
L..n.V a 1 7 -"ti
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 Driver's license 7, � ` 1 -2 -
Signature
Signature of 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.
Signature ofgn
i
f City Clerk or dese%
Approved application
DCI report
State certified driving record
Website update
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ate
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Office Use Only —�r o i�
aenrtnxiDRivenDOPaPPL92014affw4ed.DOC 07/2016
�rAug;17 2O16µ2:48PMC1air— of Grimiest Investigation 00/12/20,616;4 0621 P
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1 aln
nPC OF
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E I
Criminal
IUWa _� I Y,
Request n`
2,ca.,rmn �5' ♦ `,`..
To: Iowa Division of Criminal Investigation
Support Operations Bureau, I" Floor
215 r. 7' Street
Des Moiues, Iowa 50319
(515) 725-6066
(5)5)725.6080 Fax
%�b�f/I y s`
DCI Account Number;
Of appli6lbie) --
From: City of iowa Ctiv
City Clerh`e Office
410 E. Washinelon Street
Iowa C(ty' IA 52240
Phone: 319-356-5041
Fax. 319-356-5497
❑Fernale I i 3/—%9'— a 4 %C%
Waiver /MJory114 OB. Without a signed -wakr from the subject of the request, a complete criminal history record may not
be releasable, per Code of town, Chapter 692.2. For comnlett criminal history record information, as ailoAvd by iaw, always
obtain a waiver ttunaOma f n.n rh....h:..:..e.h_ ..__.
Waiver Release: i hereby sive permission for the above requutino ofrrci/l to conduct an len, criminal hiltory record ohWk w th the Division ofcrimiml
rweatigador (DCO. Any Criminal history data conuming me that is maintained by We Malay be released as allowed by Inv.
Waiver Signature;
Iowa Criminal History Record Check Resul
As of a search of the provided nano and date of birth revealed:
No Iowa Criminal History Record found with DCT
❑ Iowa Criminal History Record attached, DCT iY
DC1 initials
DCI -77 (08/25/10)
Received Time Aug, 12. 2016 4:28PM No, 1615
(Ouse only)
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CIOWADOT
SMARTER I SIMPLER I CUSTOMER DRIVEN vvww•Iowadogov
Office of Driver Services
PO Box 9204 1 Des Milnes, IA 50306-9204
Phone: 515-244-9124 I SDO-532-11211 Fax: 515-239-1837
vnvw.karadot.gov
Certified Abstract of Driving Record
Inquiry Date: 8/26/2016
DL/ID #:
775ZZ6832 (IA)
Customer #:
3874967
Class:
D
Name:
Mohamed Bakheit, Ismail
Audit #:
8317464
Address:
1837 GRYN DR
Issue Date:
08/02/2014
VAL
CDL Status:
Expiration
07/04/2019
ELG
Date:
]>•
City/State:
IOWA CITY, IA 522464406
Endorsements:
3
Mailing
1837 GRYN DR
Restrictions:
NONE
Address:
Restriction
None
Mailing
IOWA CITY, IA 522464406
Supplement:
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City/State:
Date of Birth:
7/4/1959
Sex:
M
History Information
Convictions
CDL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status: None
CDL Med Status: None
Citation Date Conviction Date ACD Explanation County JUR
)9/08/2013 103/27/2014 N82 .Improper Backing Johnson IA
Accidents - Accident involvement Indicated does NOT mean the individual was at fault or given a citation.
Occident Date Case Number IUR
19/08/2013 .756111 IA
11/22/2014 '.830163 IA
Name: Mohamed Bakheit, Ismail DL/ID: 775ZZ6832
Pursuant to Iowa Code 4321.10, 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:
�_
8/26/2016
o // IOWA•'•
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Office of Driver Services -
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Iowa Department of Transportation .
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Name: Mohamed Bakheit, Ismail DL/ID: 775ZZ6832
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