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CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 356-5040
(3 19) 356-5497 FAX
1. Name (REQUIRED) _
IDENTIFICATION NO. 16 c� 3
(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
2. Address (REQUIRED) 2.5q5 C1
3. Contact Information (REQUIRED) Email:
Middle
�f4V1oa�Coh�
(All written communication sent via
4a. Driver's License expiration date (REQUIRED)
03-2o- 2 oi-7
b. Taxicab Business Name (REQUIRED) _ �yy� ��� ( � Uclts
5. Prior experience in transportation of passengers:
Last
1, IOWA CITY, 1A 5z24�
Cell Phone: 319-460'3242
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
ao
Type of offense W here
When
What happened to the charge? (Circle one)
N_
Convicted Dismissed Deferred Suspended Plead Guilty-. OthekQ
Have you been arrested / charged with any traffic offenses in the last five years?
Where c _ /o-] rev , i
Type of offense f\3_o
rT
What happened to the charge? (Circle one)
c>
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? Al O
Tvoe 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) No
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)
072016
l
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I he�reby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
76 ` 0 AH71 Z6 issued on -NA-16 expiring on o3/2o/2o(-7 . 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 51 Cha ter 21 of the City
Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant C(J/Y Date q - 2q,
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by f (��T
M A "CXQ � , tT\ pe 16 on this Z t day of
,, gip$ -Loo
et'i a WENor S. MAYER Notary Public in d for the State of Iowa f
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).
Expiration date of Driver's license /�(1'
Signature of Police ief o� nee
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.
1Lk4i i/v
Sig ture of City Clerk or designee
91,;7_ elll
Date
Office Use Only o
m
V3
Approved application
DCI report c ry
State certified driving record
Website update •F
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GerkfrAXIDRIVBADGEAPPL92014amended.DOC 07/2016
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STATE Q7 F I[Q�WA.
�f' ,� CTIMWu History ry Recar' dl Check
0`�" w RequeSt Form"
70: Iowa Divisian of Criminal InveStigstiotl
Support 01""'800115 Bureau, 1" Floor
215 P. 7" Street
Des Idoines, Iowa 50319
(515) 725-6066
(51.5) 725-6080 Fax
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DCIAccoualtNumber: to02 - (,
(ifappliuble)
From: Cltv of Iowa City
City Cledt's Office
-410r. washfnatou Street
ra.va Ciiy, Ir, 52240
Phone: 3 1 9 356-5 041
Fax: 319-3565497 "—
So
ASN I R
ffmale ®ramal. 13 q 6l - 1-7-0-S-
72-
rrarver U1JOrrytar1011: without a signed wafverfrom the subject of fie request, a complete criminal h(story record may not
be. releasable, per Code of Iowa, Chap(er 692.2. For cam Mate criminal hislory 1 ccord lnfarn
obtain a waiver of nature from 1112 sub'eet of th request. sa(ion, as allowed by law, always
Wfflver Re/Base;lhercbygive permission for um above requcsli.gofficial to Bond e1 an lows criminal hislory record check wish The Division orCrimtaal
(m'esligalion (pCl), any criminal Ems), dalaeenccmfne me 0 al is mainuincdby The lmay he relcaSed Pt allotvedb Merv.
WaiverSign(Iture:
Iowa �rinlinal )f�istor IlSecorr� �➢1(•cli IBesults � —
• (Del use any)
As of ('r� (o a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI I t:7
I� Iowa Criminal history Record attached, DCI #
�U
DCI initials_
_ N.
T D0I.77 (06/25110)
RPrPlvpd Tlmt. Seo. 19. 9016 4:39PM NIo.9990
Inquiry Date: 9/28/2016
Customer #: 6005005
Name:
Address:
City/State:
Mailing
Address:
Mailing
City/State:
Date of Birth:
Sex:
DOT
SMARTER I SIMPLER I CUSTOMER DRIVEN VWAV l madot. g01J
Eltyeb, Mahmood Bashir
2545 CLEARWATER Ci
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-9124 1800-532-11211 Fax: 515-239-1837
WwwJowadot.gov
Certified Abstract of Driving Record
DL/ID #: 620AH7686 (TA)
Class: C
Audit #: 9980788
Issue Date: 05/04/2016
Expiration Date: 03/20/2017
IOWA CITY, IA 522464139
Endorsements: NONE
2545 CLEARWATER CT
Restrictions: NONE
CDL Permit
Restriction None
IOWA CITY, IA 522464139
Supplement:
3/20/1973
M
History Information
CLEAR DRIVING RECORD
Name: Eltyeb, Mahmood Bashir DL/ID: 620AH7686
CDL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
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:
"•.�% y 9/28/2016
IOWA % i
:ff�
). 0. T.; q
r�D.10 Office of Driver Services
Iowa Department of Transportation
Name: Eltyeb, Mahmood Bashir DL/ID: 620AH7686