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Home My WebLink About16-197IDENTIFICATION NO. )(0— k `-, 1 l t (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday- Friday) 410 East Washington Street Iowa City. Iowa 52240-1826 Failure to complete the "required" information will result in denial of the application (319) 356-5040 (319) 356-5497 FAX First Middle Last 1. Name (REQUIRED) ES Lt 011, 1-\ Flo Lit" wed 1, o Ur 2. Address (REQUIRED) �__6_$ Z R a S 2 cl �� `� (1 I0 I -C6 ti .1 ! Z-2, LI 3. Contact Information (REQUIRED) Email: 5u tytt 2c0 9 IAnkjma.Lrn" Cell Phone: _ya4-t(4�-Zy�p (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pa ,e_k�neY1S Cela 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? / j 6 Tvoe of offense Where When 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? N t) Type of offense Where When 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? N(7 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) 0712016 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 `d U Q M s2 �Z� issued on oR/l4(2016 expiring on o► (ol(7n�.0 I understand that f 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 � XA � Date oq1081 f6 STATE OF IOWA ) COUNTY OF JOHNSON ) tbscribed and sworn to before me by Savn %o%av- on this �Sk� day of in and fo-r the State of Iowa -11.3111 H+*mttXkH`ti+tltfffMtit kmmitHfflkttfnlkfMR1#+f+#RiynF�*y;lf++flttyt�lM++/e+yfffiftttt+ 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 Cf"f Iowa City (Title 5, Chapter 2, City Code). Ws license 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. ��X . 7"�/ SignafM of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update Date ClerkrrAXIDRNBADGEAPPL92014e ded.DOC 07/2016 FYeSe.D_.1. -2016w 5_00PM��kDiv of—Criminal —Investigation 05/30/20161a:9No,3232 P. 1/3 .. .. aaa ..-..�iooz STATE O F IOWA caul finzE History Recopidl (Cheek Request, 1Folrmuo 7'0: Iowa Division orcriminal Investigation Support Operations Bureau, l" Floor 215.E. 7" Street Des Moines, Iowa $0319 (515) 725.6066 (515)725-6050 rax I am reauestino au Iowa Criminal Histosv Reenrd Cherle nm DCI Account Nuluber: V 0 O (if applicable) Frons: City orlown City City Clerk's Office 410 F. Washington Street Iovia City, IA 5220,0 Phone: 319-356-5041 Fax: 319.356-5497 Last Name (mandatory) First Name (maadatoly) Middle Name reconlmnsded) fv o }? A.M M tv - S-A A[ AVM 2✓ 1D Bate of Birth (mandalary) (`vender (mandatop•) Social Security Number (recommusded) 1 I O I I r Male [bemale ► q s-� ti GPaiverbiforaraffont Without a signed waiver from the subject of the request, a complete criminal history record may not be rclessoble, per Code of Iowa, Chapter 692.2. For comnletq crlminal history record information, as allowed by law, always obtain a waiver signature from the subject of the request. Waiver Releaae: l herebygive permission for the above requesting official to conduct an lona criminal Isistory record check with die Division of Criminal tmxsrigation (DO). Any criminal history data concerning me chat is maintained by slit DCI may be released as allowed by law. WaiveraSignalure: c-'--•-.•.•-•,•a".["-"'�-. \ i 1Rlwi'YM N� Rowa Criminal History Record Check Results As of "`+.-( J a search of the provided name and date of birth revealeii: o - Iso lova Criminal History Record found \vjtl) DCT -i C r D lova Criminal History Record fattached, DCI N :a DCI initials_ DCJ-77 (0S/25/10) Received Time Aug.30. 2016 2:41PM No -2943 �AJ1 ADoT www.iowadot.gov SMARTER I SIMPLER I CUSTOMER DRIVEN Office of Driver Services PO Box 9204 1 Des Moines, IA 50306-9204 Phone: 515-244-9124 1800-532-1121 1 Fax: 515-239-1837 www.iowadot.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, Sam[ 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: - •:;�i''4 9/6/2016 IOWA D. 0. T.G'�J�� f RRIVEF Office of Driver Services ""DRIVIT, Iowa Department of Transportation Name: Mohammed Nour, Sami Ahmed DL/ID: 124AM2837