HomeMy WebLinkAbout16-1964
31 �III��
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa S2240-1826
(3 19) 356-5040
(319) 3S6-5497 FAX
IDENTIFICATION NO. ) 6 — 1 q t
(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 Middle Last
1. Name (REQUIRED) ES Et 011, IAy Vl VAPd (.A0 hct w wi ear ,0o tlr
2. Address (REQUIRED) 2 6.52 FAD V)e4A�S 2 CI ljP-1 `) I,) toLr'ciFTja �,-)z4�
3. Contact Information (REQUIRED) Email: 54 n9 t 200 tiz kn - wtmcLca� Cell Phone: Na4 a14fi -Z4 �?
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) o l l o l I ?-07-q
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? lJ 6
Type of offense
What happened to the charge? (Circle one)
Where
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
What happened to the charge? (Circle one)
Where
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
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 certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
;_U A M q 9 :KK 7= issued on n9It4( 2o16expiring on of totIJr, 7.0 . 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 of a Notary Public)
Signature of Applicant &A Q Date o q o 8 1 u
STATE OF IOWA )
COUNTY OF JOHNSON )
)+�n.a a� #� f0ovav- on this a da
,subscribed and sworn to before me by Sq M � a�»., y of
6. aotlp. _ \_\N _
in and for the State of Iowa
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 C"f Iowa City (Title 5, Chapter 2, City Code).
;r's license //-
r g64
or desianee 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.
Signa re of City Clerk or designee
Date
•#1f#1111#111f111f1111111m,11#1111111111111111111#,#:,,,+f#+*111#1111111111111111#,+*:,+++1+11x11111111111111»1111111:1++##11##1+111++1111111
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Geek7AXIDRN64DGEAPPL92014an ded.DOC 07/2016
„,Sep_ 1. 2016x, 5_OOPM Div of Criminal Investigation No. 3232 P. 1/3
-.lesrk —...__ _._ ____ ._. 06/30/2016 14:6.. ..063 . .....-e/002
STATE OF IIDWA
COW32E Histtolry Recokd Check
liG , :• ; Request, 1Fairm
To: Iowa Division of Crimihal Investigation
Support Operations Bureau, I” Floor
215 E. 7" Street
Des Moines, Iowa 50319
(515) 725-6066
(515)725-6080 Fax
I am repuesrino an fntva Criminal Hisfmv Recnrd Pho V nn•
DCI Account Number: V o 22=-7r—
(if applinble) (ifopplinble)
From: City of lows City _
City Clerh's Office
410 9. Washington street
Iowa City, IA 52240
Phone; 319-356-5041
Fax: 319.356-5497
Last blame (mandatory)
First Plaine (mandatory)
Middle Mame recommcnded)
[A6 H11 A AA M GU �1 o t?
G -A A r
A V ME� Q
)late of Bil•th (mandatary)
Gender (mandatory)
Social .Seettri Humber (recommcnded)
O 1
Male Ebemale
� 9 R- 5q- c; D
%raiverb ornlnfton Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasoble, per Code of Iowa, Chapter 692.2, For complete crlminal history record information, as allowed by taw, always
obtain a waiver signature from the subject oftherequest.
WaiverRelease; Ihereby gimpermosionfor the oboverequesting oMoialtoconductanions.criminalbimlyrecord checkwith deeDivision a Criminal
Investigation (DCI). Any criminal history data eonoemin, me that is maintained by [lit DCI may be released n5 allot+rod by law.
Wffiversigneture;
Iowa Criminal History Record Check )�)i
As of a search of the provided name and date of birth revealed':
No Iowa Criminal History Record found will) DCI
[i';
El lows. Criminal History Record atttaclied, )XI # :J
DCI initials"Wi
DO -77 (0S/25/10)
Received Time Aug. 30. 2016 2:41PM No. 2943
go'NOWADOT
SMARTER I SIMPLER I CUSTOMER DRIVEN www.iowadot.gov
Office of Driver Services
PO Boz 9204 1 Des Moines. IA 50306-9204
Phone: 515-244-9124 180D-532-1121 I Fax: 515-239-1837
www.lowadot.gov
Certified Abstract of Driving Record
Inquiry Date:
9/6/2016
DL/ID #:
124AM2837 (IA)
CDL Permit Class:
None
Customer #:
6536210
Class:
D
CDL Permit Issue
None
Date:
Name:
Mohammed Nour, Sami
Audit #:
1242837
CDL Permit
None
Ahmed
Expiration Date:
Address:
2652 ROBERTS RD APT 2D
Issue Date:
08/19/2016
CDL Permit
None
Endorsements:
Expiration Date:
01/01/2024
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522462740
Endorsements:
2
ID Status:
None
Mailing
2652 ROBERTS RD APT 2D
Restrictions:
Corrective Lenses
DL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522462740
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
1/1/1976
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
CLEAR DRIVING RECORD
Name: Mohammed Nour, Sami Ahmed DL/ID: 124AM2837
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:
:- •;v/'4
9/6/2016
IOWA
D.O.T. ��*'s
'
f�(
Driver Services
Office of
Iowa Department of Transportation
Name: Mohammed Nour, Saml Ahmed DL/ID: 124AM2837