HomeMy WebLinkAbout16-227�III�
CITY OF IOWA CITY
410 Ea5l Washington Street
Iowa Clty, Iowa 52240-1826
(3 19) 3S6-5040
(319)3S6-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED'
IDENTIFICATION NO.
-aa-7
(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
3. Contact Information (REQUIRED) Email: $h4b7+94 Pc
rm& %Wwt Cell Phone: 311- ?SS 5-Y 1 7
(All written communication sent visa email)
4a. Driver's License expiration date (REQUIRED) 5_0 A G 3 6 2 b
b. Taxicab Business Name (REQUIRED)C " Cay
5. Prior experience in transportation of passengers: 5-
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? n
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? ire$
Type of offense Where When
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What happened to the charge? (Circle one) Ok
!C c
Convicted Dismissed Deferred Suspended ad Guilty Other,
le
Pte' `y
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five &rs?
i
- 4-1
Type of offense Where en - t
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide thio
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
�;-(q ✓i G -� (� 2 G issued on v$ / i7 /2dh expiring on cd/11 l 20 2.�j. 1 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 applica n, n^d I further agree that, if authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions 4f itl 5ehapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date fo//o �) h
fl11HHlYTf»1111 f'�F4HfHHYf f 1f»»»»f!HllHfHlf4fff»i4fYlflHlf f 1f11fYfff 1flHf»HH»H,HH1»fHff Hl1f!!!f»1!111»f»Y44ff ii'4iYYlY
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Ak*,,.M . Kpo xaam g„ -tk on this (O day of
h, -0- 7__t-1 / 1 a _
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 o�wa City (Title 5, Chapter 2, City Code).
Expiration
designee
//
Dat
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.
Sign City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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STATE, OF IOWA IWG
( rima, IlHistory di l;Checls
Request
n
Form
To: Iowa Division ofCritninal Investigation
Support Operations Bureau, lit Floor
215 E. 7" Street
Des 141oines, Iowa 50319
(51 5) 725-6066
(515)725-6080 Fax
I am requesting an Iowa Criminal His(ory Record Check on -
DCI Account Number � �'7_-f=
(if applieable)
From: City of Iowa Cit
City Clerles Office
910 E. Washington Street
rows City, IA 52240
Phone: 319.356-5041
Fax: 319-356,5497
Last Name (mandamry)
first Name (mandamry)
Middle Name (recommended)
Nlo�nmN,c�1
,gGmeJ
NIUS G
Date of Birth (nsondelory)
Gender (mandatary)
Social Securit v Num/ber (reaan,menaed)
05h ! IR 66
1Male ❑female
�� 3' 1 GG
Waiver InfOMN1011, Without a signed waiver ❑•om thesubject of the request, a complete criminal history record may not
be releasable, per Code of lows, Chapter 692.2. Fml• cow criminal history record Information, as allowed by law, always
obtain a waiver slnature from the subject of the request
Waiver Release: I bcaby give permission far she a ovcregnesa official to conduct en lona criminal hialoty record chtek with um pNision orClmdnal
Investigation(OCI). My criminal hislory dose coneemir at it DCO moy be« lensea as allowed by lay.
WniverSignafm•e: ��
Iowa Criminal History Record Check Results (DCt use only)
As of a search of the provided name and date of birth reilealed:
No Iowa Criminal History Record found with DCI •
C� Iowa Criminal History Record attached, DCI
---- r=
1) CI
DCI -77 (08125110)
Received Time Aug. 15. 2016 2:58PM No. 1713
Page 1 of 2
C,410WADOTSIMPLER I CUSTOMERDRIVEN' WUVW'IOVUadC)goV
SMARTEBI
Office of Driver Services
PO Box 92041 Des Moines, IA 50306A204
Phone: 515-244-9124 1806-532-1121 I Fax: 515-239-1837
www.iowadol.gov
Certified Abstract of Driving Record
Inquiry
8/17/2016
DL/ID #:
519AG3626(IA)
Date:
None
Endorsements:
Customer
5827626
Class:
A
ID Status:
None
DL Status:
VAL
Name:
Mohammed, Ahmed
Audit #:
1235369
Status:
Musa
CDL Cert Status:
Non -Excepted Interstate
Address:
1147 WINCHESTER LN
Issue Date:
08/17/2016
Physician Ass_ista_nt_
_ _
Medical Certificate Issued_ Date
Expiration
09/11/2024
Medical Certificate Expiration Date
Date: -
Date Added to CDLIS Driving Record
City/State:
NORTH LIBERTY, IA
Endorsements: NONE
523179162
Mailing
1147 WINCHESTER LN
Restrictions:
NONE
Address:
Restriction
None
Mailing
NORTH LIBERTY, IA
Supplement:
City/State:
523179162
Date of
9/11/1966
Birth:
Sex:
M
CDL Medical Examiner's Certificate
CDL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
_
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
Medical Examiner Last Name
ID Status:
None
DL Status:
VAL
CDL Status:
VAL
CDL Permit
ELG
Status:
CDL Cert Status:
Non -Excepted Interstate
CDL Med Status: Certified
Certificate Specifics
Explanations
_ _ _ _
_
Medical Examiner First Name
Medical Examiner Middle Name
wls
Medical Examiner Last Name
Nelson
Medical Examiner License Number
_L002023_
Medical Examiner National Registry Number
_ _
7661525813
Medical Examiner Jurisdiction
IA
__
Medical Examiner Phone
_
(319) 358-5736 j
_
Medical Examiner Type
_ _ _ _
Physician Ass_ista_nt_
_ _
Medical Certificate Issued_ Date
Medical Certificate Expiration Date
107/31/2017
Date Added to CDLIS Driving Record
08/17/2016
History Information
Convictions
:nation Date Conviction Date ACD Explanation County JUR
.1/05/2011 11/30/2011 jS92_rFall
Johnson I _
.1/09/2014 03/18/2015 �M34 Obey TrafFlc Sign/Signal Johnson'— J ___— --_' _ --
.1/09/2014 03/18/2015 iE55 Without Headlamps or With Park LampsJohnson IA
.1/27/2015 112/18/2015 j er Registration Johnson ;IA
8/17/2016