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Home My WebLink About16-198� r 1 CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (319) 356-5040 (3 19) 3S6-5497 FAX IDENTIFICATION NO. 1 6 — I I$_ (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) Flet 01, hc(wr w1 eaf IJ our 2. Address (REQUIRED) `.� ! S 2 R O toettS 2 CI 10-1 e> ( 10 UCCi 4-q�If JA 2,4/ 3. Contact Information (REQUIRED) Email: 5u VI t 2oD G�Idok wau nH Cell Phone: _�(at{�14ti-Z4�2 (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) o d o l l 20 2 t4 b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of pa CA iHEY1S UA. - 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere 1J 6 Type 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 b 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? NO 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 19- AAA 2 $ 3 :�— issued on n R f 14 ( 2016 expiring on o l Ll l `/ p zq . 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 �f �o xA Date v q o 8 f6 G' STATE OF IOWA ) COUNTY OF JOHNSON ) ubscribed and sworn to before me by Darn+ �)+�.ao%�ax,., Noor on this b day of b.� aotl�. in and fo'r the 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 theGi"f Iowa City (Title 5, Chapter 2, City Code). -i's license�- g 6-d 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. 247 t� 9f' • 26L-4/ Signathge of City Clerk or designee Office Use Only Approved application DCI report State certfied driving record Website update Date CledJr=DRRfBADGEAPRL92O19emmded.DOC 07/2016 FfeSep_ 1. 2016„_§ OOPM�IBrkDiv of Criminal Investigation No. 3232 P. 1/3 s -A M[ 08/3or2n,6,a,6 Gender (mandwop•) STATE OFMW' A Requaft Form To: Iowa Division of Criminal Investigation Support Operations Bureau, Is' Floor 215 B. 7" Street Des Moines, Iowa $0319 (515) 725-6066 (515) 725-6090 Fast I ani renuesrina nn fnwa Criminn) Histrnv Recnrri Chenlr nn - DCI Account Number: (if apphable) From. City oflown City _ City Cleric's office 410.L, Washington Street Iona City, IA 52.240 Picone: 319-356-5041 Tax: 319-356-5497 Last blame (mandatory) First Name (mandatory) Middle Name reconnamded) [0 a 61A.M M tD 0 o LP K s -A M[ Date Of Firth (mandatory/) Gender (mandwop•) Social SecurityNumber (recommended) O I u I 1bMMale OFcmale R— 25 Waiver biferniationt without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chaplet, 692.2. For comnlete criminal history record information, as allowed by law, always obtain a waiver signature from the subject of the request. Waiver Release; I hereby give pemission for the Above requesting orficinl to cordon an rouz criminal It record cliceb with me Division of criminal Invesligmton (DCI), Any aimlnal history data coneemin.-me tbat is nuintained by the DCI may be reieascd ns allowed by law. WaeverSign ature: tLVYr4 tL.aalrllralr; AAY`J Llyl Il6l:Gtld-tY Y..lrlrCK A�CSUl9.3 <�' (DCl fisc olOp) As of a search of the provided name and date of birth revealed; Nto Iowa Critninal History Record found witb DCT O Cf r, ❑ lows Critninal History Record attached, DCI 0 c, DCI initials ,f) DCj-77 (0g/25/10) Received Time Aug.30. 2016 2;41PM No.2943 '10WADOT SMARTER I SIMPLER I CUSTOMER DRIVEN VVWW,IOWBdot.gov Office of Driver Services PO Box 9204 1 Des Moines, IA 50306-9204 Phone: 515-244-9124 1 8OD-532-1121 I Fax: 515-239-1837 www.lawadot.gov Certified Abstract of Driving Record Inquiry Date: 9/6/2016 DL/ID #: 124AM2837 (IA) Customer #: 6536210 Class: D Name: Mohammed Nour, Saml Audit #: 1242837 ID Status: Ahmed DL Status: VAL Address: 2652 ROBERTS RD APT 2D Issue Date: 08/19/2016 CDL Cert Status: None Expiration Date: 01/01/2024 City/State: IOWA CIN, IA 522462740 Endorsements: 2 Mailing 2652 ROBERTS RD APT 2D Restrictions: Corrective Lenses Address: Restriction None Mailing IOWA CITY, IA 522462740 Supplement: City/State: Date of Birth: 1/1/1976 Sex: M History Information CLEAR DRIVING RECORD Name: Mohammed Nour, Sami Ahmed DL/ID: 124AM2837 CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: CDL Permit None Endorsements: Iowa Department of Transportation 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 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: •""••;'z/V,� IOWAy�iea.J�f 9/6/2016 79rRRIYER g� Office of Driver Services 11/81110/ Iowa Department of Transportation Name: Mohammed Nour, Sam! Ahmed DL/ID: 124AM2837