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Home My WebLink About16-190d= CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (319) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. )62-190 (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 Last 2. Address (REQUIRED) r3Ll2-%,iic(, ,nP l��ttr -.toi.AJ C-.'6 -f,Lj '5L2y 6 3. Contact Information (REQUIRED) Email: Lo+etz2 � Cell Phone: (All written communicatl6n sent via email) / 4a. Driver's License expiration date (REQi b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Where What happened to the charge? (Circle one) When Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where When What happened to the charge? (Circle one) :� Convicted Dismissed Deferred Suspended Plead GuiW Other .. t c-, N 8. Has your driver's license or chauffeur's license been suspended or revoked in the last fivEt s? Type of offense Where he i 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) l) 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 1 hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number 6 f oqa cul, issued on expiring on O1- nf-'70/x. 1 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_ Date -9/2/2,V +xxxxxx+++xxxxxxxxxxx+x+++xxxxxxxx+++++xxxxxxxxxx++++++xxxxxxxxxxxx+++++++xxxxxxxx+xx+++++xxxxxxxxx+++++xxxxxxxxxxxxxx++++++xxxxxxx++++++++++xxx STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by \ `+ CN (\ )jAnn ir0 Wb\ -WA -e. on this Z— day of 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 1lZ%Zd�Y Date Q5lv� Signature of Police Chief or designee 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. Sign a of City Clerk or designee ate xxxx+++++++xxxxxxxxxxx++++++xxxxxx++++xxxxxxxxxxxx+++++xxxxxxxxxxx+++++x+xxxxxxxx+x++++++++xxxxxxxxx+++++x+xxxxxxxxxxx+x+x++++xxxxxxxxxxxxxx++++ Office Use Only Approved application DCI report State certified driving record Website update Ger AXIDftNAADGEAWL92014a"ndW DDC 07/2016 N � r�1 :�y o Ger AXIDftNAADGEAWL92014a"ndW DDC 07/2016 C U ii, DOT SMARTER I SIMPLER I CUSTOMER DRIVEN WUVW'IOWadDt.gOV Page 1 of 2 Office of Driver Services PO Box 9204 1 Des Moines, lA 50306-9204 Phone: 515-244-9124 1800-532-11211 Fax: 515-239-1837 wvAvJ(w/adot.gov Certified Abstract of Driving Record Inquiry 9/2/2016 DL/ID #: 669A72746 (IA) CDL Permit Class: None Date: S93 Speed MD Customer 6063417 Class: D CDL Permit Issue None #: Date: Name: Mohamed, Mahmoud Audit #: 6692746 CDL Permit None Expiration Date: Address: 342 FINKBINE LN APT 7 Issue Date: 02/13/2013 CDL Permit None Endorsements: Expiration 01/01/2018 CDL Permit None Date: Restrictions: City/State: IOWA CITY, IA Endorsements: 3 ID Status: None 522461714 Mailing 342 FINKBINE LN APT 7 Restrictions: NONE DL Status: VAL Address: Restriction None CDL Status: None Mailing IOWA CITY, IA Supplement: CDL Permit ELG City/State: 522461714 Status: Date of 1/1/1977 CDL Cert Status: None Birth: Sex: M CDL Med Status: None History Information Convictions :itation Date Conviction Date ACD Explanation County ]UR )7/04/2013 07/29/2013 S93 Speed MD Sanctions Type Effective End ACD Explanation Occurrence ]UR IUR Suspended 02/11/2014 07/08/2014 Fail to Post Security for an Accident -Owner Only 'IA IA Name: Mohamed, Mahmoud DL/ID: 669A72746 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: -'0W6If , .�........ /b.�1e http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 9/2/2016 F,Aug: 19, 2016,11:28AMCe1Div of`Criminal �Investigation No. 1065 P. 1/4 -^ o my -m 1 06/16/2ola Isna Vano V.00a/003 r° (Clrntnrlli_rgial lH[i�story Record gMeck .� Rcgjuest Form, , TO: Ioeva Division of Criminal investigation Support Operations Bureau, 150 Floor 21S E. 7'1' Street Iles "Ofiles, Iowa 50319 (515)725.6066 (515) 729-6080 Fax an Aowa Criminal History Record Checkoff: UCI Account Dlumher: ot'Z (if npplicrble) iron; —!9A1 ofIowaCl City Clerk's Office 410 C. Washington Stroct Iowa City, IA 52240 Phone: 319-356,5041 Far: 319.356-5497 CL1r�jY, N Date of Mrth(nlanearory) Gender mandatory Social Security Number(aeona,eadad Waiver 1'nfof7rta[ion: Wittrcut3 signed waiver from the subject of the request, a complete criminal history record may rot obtain a waiver signature froth the sttbleot of the ra- upCO) be releasable, per Code of Iowa, Chapter 692.2, For cot". ts- erlshinal history record information, gs allowed by law, always 1Faivdr' Rek4fse; I hereby give permission for the abovare411cs4118 official 10 wnduct an Iowa criminal his,ary record claccic wish the Division Of Criminal fnvenleelion (DCI). My criminal hinory darn coneemin, me Thar isnla(nlainc by the DCI May bereleascd as allowed by lag. diverSig(trr[61re: I '\A '.-n. All Iowa Criminal flistor Record Che k ReeIalts F(DC1As of a search of the provided came and date of birth revealedNo Iowa Criminal History Record found with DCII:: D Iowa 01iminal History Record attached, DCI DCI DCI -77 (08/25/10) Received Time Aug, 16. 2016 3:56PM No. 1820