HomeMy WebLinkAbout16-224IDENTIFICATION NO. _ f Q - ZZt I _
(Office Use O )
CITY OF IOWA CITY Oct
APPLICATION FOR TAXICAB 1 MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. ll 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) ZS \ 1.tk\n
2. Address (REQUIRED) ?L >; it Yuhes4S ragct A P� D
CM
3. Contact Information (REQUIRED) Email:...a`���-�.u.�cr-..a,e\�\ial.«:� Cell Phone: 3l q..2t n
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
Prior experience in transportation of passengers. _ S Yec. r
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Gui Other
7. Have you been arrested / charged with any traffic offenses in the last five years? NO
Type of offens Where When
What happened to the charge? (Circle one)
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? -/0--
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 thefiame(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)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
1. 1�!zr�) issued on ( 11�expidng cn 1P ,2 T(� I understand that if I
fa se y answer any questions in this application, that this a plication m y 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—W — (] _ / 6
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn r to before me by Flo( taw p sQ T_ . t 1..55 kq on this 2� 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 City of Iowa City (Title 5, Chapter 2, City Code).
Expiratio dat f au eur's license
Sign to ure , f Po c i 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.
�l tTLte¢•xai `� `�A�iy
-ature of City Clerk or designee
Date
X I X. I YXR RH# fafn ir..####11f}f1XififXif4lflHi##H#titffaHafii#i#ii#i#Y##iiHiif#fifff+##i;Hif#X1X... Hlfh>f!XlHfXXikHikH}ftf
Office Use Only
Approved application
DCI report -
State certified driving record
Website update
• n�
CWN/rAYJDRNBADGEAPPLS2014affend lDGC 0312015
Jun. 21. 2016 9:12AM Div a` Criminal Investigation No. 8343 P. 1
,Fre ., w.. GI by4. _...__ 05/21/2016 7710_ ..662 ....D2/DD2
STATE .1r a IOWA
Criminal History Record C
Request t..
f
Rp
'fn: fowaDivislonofCriminal Investigation
Support Optraiions Bureau, I" Floor
215 Z 7" Street
Des Mohies, Iowa 50319
(515) 725-6066
(515)725-6080 Fax
I aln racuesline An Town CriminnI Mtrnw koYnvd rl,aol.
art
DCI Account Number: o/
(iftpplicahlc)
From: Cityarlowa City _
City OWN office
410.E. Wash)ag(on Street
Iowa City, IA 52240
Phone: 319-35&R41
Fax: 319-356-5497
Last Name (mandatory)
First Nante (raandalo
Middle Name (reeammendw)
S� �A
Date of firth (man�fdatary)
treader mandator
Social Securi Numb el, (rccommeddtd
l_-. o) q 9-1
(Male �Fcmale
Waiver 111jorolation: Without a signed maiver from thesublect ortlle request, a complete criminal history record may not
be roleasAble, per Code of Town, Chapter 692.2. For coiripleta criminal history record tuformatimr, as allowed by law, always
obtain a waiver signature Irom the subject of the request,
Wall'ed' Release; Ihueby give permission for the abovo regoesOng offcial to candoct an 1o%" arlmbui htsldry record ehtek with the Division oI CrimlaRl
llwww%aon (DC)). Any criminal history daW eoaCenli,r„ me nut is mahla�ineed by the DCI may be released ns avowed by hw•.
WalversTerfatilre:
Iowa Criminal History Record Check Results (DclUSE any)
As of 6:2JL2 , a search of the provided name and date of birth revealed:
No Iowa Criminal histoi3f Record found with DCI
C.i (kQ
® lowa Criminal history Record attached, DCT tF h
DCI itlitials�:/�%
ul+1-11 IVa/LJ/ I V)
Received Time Jun, 21. 2016 4:50PNI No. 6044
�^�+ I ®Wa o oT
SMARTER I SIMPLER I CUSTOMER DRIVENVWVW.IOWBdOt.gOV
Office of Driver Services
PO Bot 92041 Des Moines, IA 50306.9204
Phone: 515-244-0124 1800-532-11211 Fax: 516-239-1837
www Icwadol.gOv
Certified Abstract of Driving Record
Inquiry Date:
6/28/2016
DL/ID #:
840AK8261 (IA)
CDL Permit Class:
None
Customer #:
6268742
Class:
D
CDL Permit Issue
None
Date:
Name:
Hussin, Mohamed Ismail
Audit #:
1104971
CDL Permit
None
Hamld
Expiration Date:
Address:
2654 ROBERTS RD APT 1D
Issue Date:
06/24/2016
CDL Permit
None
Endorsements:
Expiration Date:
01/01/2019
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522462741
Endorsements:
3
ID Status:
None
Mailing
2654 ROBERTS RD APT 1D
Restrictions:
NONE
DL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522462741
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
1/1/1983
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
03/02/2016 910757 IA
Name: Hussin, Mohamed Ismail Hamid DL/ID: 84DAKS261
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:
Ou�� 06h r
1 o��10WA��y'R
4 of �914��
Name: Hussin, Mohamed Ismall Hamid DL/ID: 840AK8261
6/2B/2o16
Office of Driver Services
Iowa Department of Transportation r_
C.i