HomeMy WebLinkAbout16-208� r i
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-S040
(3 19) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO. ( b - S'
(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 I ast
3. Contact Information (REQUIRED) Email: Cell Phone: 70
(All vften communication sent via email)
4a. Driver's License expiration date (REQUIRED) //. -15..2 0 /6
b. Taxicab Business Name (REQUIRED) <aZ f irYr e-rT ' • t
5. Prior experience in transportation of passengers:
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or else
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?
Type of offense Where When
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Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? 1
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
g2;2!2 4 k 0 55e<2 issued on qleflRoI4 xpiring on /IZ1 .?61A . 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 Titl 5 Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant, Date
rn 1.,t
C71 —
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STATE OF IOWA )
COUNTY OF JOHNSON ) –
before
I
this Iq day of
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 hof Iowa City (Title 5, Chapter 2, City Code).
license I f / 2S12,
or
fl U
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.
k . -ea-AA-1
Signa re of City Clerk or designee
! &_I/ I .
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
CIeAJTAXIDRIVBADGEAP L92014am nde .DOC 07/2016
Frbep._lo• ivioµ 3:ioriViCI er,uiv oT vriminaiy Investigation
,,.Sep. 16. 2016, 9:34AM,,,,,Div of Criminal Investigation
110. 31y7 r. v i
09/15/2075 00:6 1376 --A1002,
09/12/2015 1 ilk 4004, 71 P:.2�2rooa
STATE OIF I(D)WA 3
(C1161uilmd i�I6§torgr Reeokd Check
Re6iaoest Form y�
To; Iowa Division of Crhnlual favcitigatlon
Support Operations Bureau, l" hloar
215 B. 71h 5(reet
DotMoinea Iowa 5031h
DCIAccoantNumber: "-,oUZ—
(Iflpplieahle)
Frain! Cltoflowa lair
City Clerl. a Oftico
410 S. Wxshing(on street
(515) 725-6066 TOA OID PA FOR row• Clly, IA 52240
(515) 725-6680 Fox
T EQ ST AGAI , Phone; 319-356-5041
PL SE RN F.ORMFoxr 319-356.507
'1 a1n reottegdar an Inw.n MMminal A(ornn, Qnnn.A 111 -1 --
Last Name (reandb(
PYrgt Mine, nunallueqI Middle Name trerosamsdtd
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We of Birth lbandaiool
Gender(nundamn) Social Security Numbeerr(rccwmeaded
095' L7Nfale �Felnale ��3�' J $ %
W4('ve ANVornt4fton; WI(1loula signed waiver from the subject of the request, a complelecriminal hlstory record tnoy not
be releasable, pbr Cod"of fewa, Cbap(0r 69.1,2, For coil, criminal hls(o1y record Informatl6a, as allowed by law, ahs•oys
obtain a Waiye).41018111R from (tie subjeot of therequest '
mullmlri4efeare;Llmr lnelWepiydatawaccoboabarelegowltneohielellocwd�drolowacrimnblhlnbrylbrordduckwill h'eD(riYon'ofCafminal
ImtsA6aaon {DCI). MraAnllnel blA"ry daNwneemingIn, lMlhmafnl nr ac 11C1 meyheldMed e,7 tIIDl1'ed oylnn'.
el
W4tLer Signefltrc(
Iowa Criminal History Record Checl+; Itcsults
(ociuganly)
zv
As of � , a seareb of the provided name and date of hirlh tevaaleil;
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No )oWa (l'iminol History Record foand wilh DCI
Iowa G7•iminal History Record nttoohed, DCl #
1$
CD
DCI initials _
DC1.77 (08/15/10)
Received Time Sep. 12, 2016 12t54PM No, 3716
Received Time Sep. 16. 2016 9:40AM No. 3148
C410WADOT.( www.iowadot.gov
SMARTER I SIMPLER I CUSTOMER DRIVEN
Inquiry Date: 9/13/2016
Customer *: 6245436
Name: Mohammedall, Way
Abuelgasim Yagoub
Address: 2449 SHADY GLEN Cf
City/State: IOWA CITY, IA 522464115
Mailing
2449 SHADY GLEN Cf
Address:
None
Mailing
IOWA CIN, IA 522464115
City/State:
None
Date of Birth:
11/25/1965
Sex:
M
Convictions
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-91241800-532-11211 Fax: 515-239-1837
wvAvJowadatgov
Certified Abstract of Driving Record
DL/ID #:
828AK0862 (IA)
CDL Permit Class:
None
Class:
D
CDL Permit Issue
None
�S92_
_ _ _
Speed
Date:
IA
Audit Jf:
1293843
CDL Permit
None
TJohnson
IA
Expiration Date:
X07/12/2016
Issue Date:
09/13/2016
CDL Permit
None
Endorsements:
Expiration Date:
11/25/2021
CDL Permit
None
Restrictions:
Endorsements:
3
ID Status:
None
Restrictions:
Corrective Lenses
DL Status:
VAL
Restriction
None
CDL Status:
None
Supplement:
CDL Permit Status:
ELG
CDL Cert Status:
None
CDL Med Status:
None
History Information
Page 1 of 1
:itation Date
Conviction Date
ACD
Explanation
County
JUR
16/21/2015
'06/26/2015
�S92_
_ _ _
Speed
_
[Johnson
IA
15/11/2016
07/12/2016 _
_
_1142
_ _
,impror Lane (changinglanes)
pe
TJohnson
IA
15/11/2016
X07/12/2016
iM85
,Texting While Driving
_
(Johnson
IA
Name: Mohammedall, Way Abuelgasim Yagoub DL/ID: 828AK0862
Pursuant to Iowa Code 4321.10, 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 1 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:
Oj��w/
o`O@�tNIEIf
s¢'IOWA "A
9/13/2016
D. 0. T...'Z
Office of Driver Services
Iowa Department of Transportation
Name: Mohammedall, Way Abuelgasim Yagoub DL/ID: 82BAK0862
9/13/2016