HomeMy WebLinkAbout16-176CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1 82 6
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) _
IDENTIFICATION NO. 16- 11 b
(Office Use Only)
APPLICATION FOR TAXICAB I 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
Middle
Last
C0 S /7741-x/
2. Address (REQUIRED) /rjjv ly)neinUll of., l0wu C'14 i%1 h 2Zc+6
3. Contact Information (REQUIRED) Email: AloeA rA 3 E' f ahv v• c o . u(c Cell Phone: G/U Z- 2- Z�
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) /2 / /I / 2 o.2,;2-
b.
rL.2b. Taxicab Business Name (REQUIRED) C LA) A /V r
5. Prior experience in transportation of passengers: Yt 5 r 5uc�rw5:-
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? W—
Type of offense
What happened to the charge? (Circle one) N/,4
Where
When I
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? ,d -*D ye S
Where
5
What happened to the charge? (Circle one) �✓/ L{
When
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
A/ 6
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 hereto certfy that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
6 S A X 22 2 issued on yq lo312,44expiring on / 2/ n leo zi . 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 ofgNotary Public)
Signature of Applicant Date e116c y
CD
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 2nfjL_ ¢._ilAr. on this SO day of
A _ l -f nrl _
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).
license ( Z I 1 1 121
F L3 011
TF ate
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.
Signalure of City Clerk ordes��
T Dal;6
1H1f11f111ffrfl+-!'ff 111HHHf HlH4Y4f+}f411fll1fHHflfYffHlf 1H11111l1IH1fH}H}fN1f111H4}1fH4}1f!}44}4HHHHf411H1f!!1H!!f}f44+}f ff
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Clerk/W ORNBADGEAPPL92014e.ded.DOC 07/2016
Iowa Department of Transportation
0 Me d DIiAR scrvkm (Tall Fmc) ()Ww532.1121
PO Box 9204, Des Malftes, lA 5MD"204 515.244-9124
FAX 515,239.1031
History Information
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
8/18/2016
DL/ID #:
686A32272 (IA)
Customer #:
6083714
Name:
Osman, Rasha
Class:
D
ID Status:
None
Mohammed
Address:
2656 ROBERTS RD
Audit #:
8222591
DL Status:
VAL
APT 1C
Issue Date:
07/03/2014
CDL Status:
None
Clty/State:
IOWA CITY, IA
Expiration Date:
12/11/2022
CDL Cert Status:
None
522462742
Endorsements:
3
CDL Med Status:
None
Mailing Address:
2656 ROBERTS RD
Restrictions:
NONE
Restriction
None
APT 1C
Supplement:
Date of Birth:
12/11/1973
Mailing
IOWA CITY, IA
Sex:
F
City/State:
522462742
History Information
Convictions
Citation Date
Conviction Date
ACD
I Explanation
lCounty
JUR
101/23/2.015
102/2q2015 2015
S92
Seed
Johnson
IA
Name: Osman, Rasha Mohammed DL/ID: 686A12272
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:
Name: Osman, Rasha Mohammed DL/ID: 686A12272
8/18/2016
w�
Office of Driver Services
Iowa Department of Transporation
Fr Aug LY, Zulu L:LbI'MC10 Ulv of ];Aminal lovestlgatlon No. 1164 P. 4/8
'— •-•—�- —•� •�•�-��__, 06/23/2016 11:1 .. 63e. ,.vv2/003
STATS OF, IOWA
CTilrninal IY,Cri olry ]Riecorro3 Cheeis
0 kReque-gt Form
To: Iowa Division of Criminal Investigation
support (Dperatioua Bureau, 1" Floor
215 E. 7a' Street
IDta Maines, Iowa 30319
(SIS) 729-6066
(315) 725.6080 Fay.
I)CI Account Number; _ 9607 -
Prom: _4:ityoflowaCl __
City Cleric's l2ftice —
410 E, Wasbingtou Street
Iowa City, IA 52240
Phone: 319-356.5041
Fax: 319-3S6-549,7
Iam re uestin all Iowa Criminal History Record Check on:
Last Name puaudamry) First Name (mandatary) Middle Name (fewmmasdcd)
3S5XA// RASNA
11/1 vN1aMi'V7En
Date of.Iiirih (mandato,,') Gender(mand3fory) _ Social Securi .Number (---------d)
®Male [Female 21 Zf y 0
17 afverinjorDrtatioru Witltouea signed waiver from thesu*ct of the request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 6912. For co_ mnlete criminal history record information, as allowed bylaw, always
obtain a waiver slon ature Prom the subi ect of ahr, rennnee
Waiver Release: I hereby give prrmheshan for she abova requesting officist to eandues an Iowa criminal historyrecord check wilb ole Division of Criminal
fnvgngmhnn (neo. Any crimloal history data coneerni ig nit Ilial Is maintolned by the DCt may be released os ellowed bylaw.
Waiver Sionafure: ice.-._ A A
Iowa Criminal Mow Record Cheep: ]Results
(DCI use only)
As ofj-2L a search of the provided name and date of birth revealed:
s•a
- No Iowa Criminal History Record found with DCI
r {..
� Iowa Criminal History Record attached, DCT-
' G
A
DClinitials
DCI -77 (08/25/10)
Received Time Aug.23. 2016 10:57AM No -2387