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Home My WebLink About16-244"1 -4 I �w CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO. I (Office UseOnly) 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 g Middle / Lasj 1. Name (REQUIRED) �S�Irolf / lgC' MWIVr14Pd-9 Aeko 4 ((uo{o 2. Address (REQUIRED) `Ly9 N�&LA6 10.-D *3Z-2-0 C Vr (ViUA4 52-+—y.t /I✓a 3. Contact Information (REQUIRED) Cell Phone: 319 5;l -L6368 (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) Aak, OLUO a Z0'L) b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: '%Ki Drit,-=r ii, Sgj,jr„- 7r yea s 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? N a Tvpe 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? IJn Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Ot* 0 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five74ears? r Tl/n Type of offense Where 9. Have you ever applied to bean Iowa City taxi driver using a different name? If yes, please drlavlde tllftnamb & N v caw 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 1315 AM Ol 5 S1 issued on 'o3expiring on DW62 zo21 . I understand that if I falsely answer any questions in this application, that this app ication may be denied. I a ree 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 J�� J Date 10Z2��2 0 1 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by A,Sj„ ,rn :C M . % j M CA– on this z-7 day of �, r #p6(f 7r.)1 LD A in bbd for the State 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). Expiration date of Driver's license 6L f3` Z( I %4Y Signature of Police Chief or designee J127&(., 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. SigndkLie of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update —T to CIerk/TAXIDRIVMDGE PL92014a.nded.DDC 07/2016 wC7 m M 'o 1 N a- w c:1 CIerk/TAXIDRIVMDGE PL92014a.nded.DDC 07/2016 /,•' ,Oct. 20, 2016,,12,19PM,, ,,Div of Criminal Investigation No, 5853 1 P. o✓�®✓zo�g73rt7<1�?2,002 S''FATE OF IOWA " Criminal ffistory Meeord Check Request To: 1011✓a Division of C'riminal Investigation Sapport C)paraeimts 80rcau, l" Floor 2I5 E. 7t" Street Des Nloirlcs, Iowa 503I9 (515) 725-6066 (515)72&6000 Fox kod04 ocf"%F3/f 9'7Y� As DCI Account Number: (ifapplicahlc) "-" rrmn' city of rnwa ci(y city Clerlt's Office �"`—" 410 li, Vi�aslsing(on Srreel Iowa Cl , IA 52240 Phone: 319-356-5041 Fax: 319-3565497 "'- 7 J1Ialc ®Nemale MO yrs wl M�K 1 I�cnL-t' 7%53-04_22/a rrarvel'tnjorttlnf[pft: Without a signed waiver from the subject of the request, a complete criminal history record may nal be releasable, per Code of Iowa, Chapier 692.2, For comulete n�itnlnal history record hlformation, as allowed re law, always Main a waiver si nature from the sub'ect ottfre re uesl. W(rive)' ReleirSe:) hereby Sire pemlission for n¢ aboro regnesling official to conduct an Iowa criminal history ruord chccl: with the Division orcriminal Im•eellgafian (DCI)• Any erirninnl hislnrydata concemiuS Inc that is maintained by the DCI may bei sed as allowed bylaw. Waiver Iowa Criminal Histol r 11ee-ord C11eClr Results As of—L�1�- a search of the provided name and date of birth revealed: No Iowa Criminal History Record found with DCT ® Iowa Criminal History Record attached, DCI # DCl initials_ DCI -77 (08/25/10) Received Time Ocl. 18. 2016 1i22PM No.6341 I use only) `i Cn 0 DOT° . .✓ t/jkviowadot gov SNI A;HIER i'I PAPLEB ICe}SI"WA F PRIVfiN Off -ice of Driver Services PO Box 9204 � Des Moines. IA 501306-92G4 Phone: 515-244-9124 1800-532-1121 1 Pax:515-235-1337 wwYd 13%vad41.gov Inquiry 10/27/2016 Date: Customer 6554075 Name: Kudoda, Ashraf Mohammedelhad Address: 209 HOLIDAY RD APT 322 City/State: CORALVILLE, IA Certified Abstract of Driving Record DL/ID #: 135AM0159 (IA) CDL Permit Class: None Class: D Audit #: 1363097 Issue Date: 10/13/2016 Expiration 04/08/2021 Date: Endorsements: 3 CDL Permit Issue None Date: CDL Permit 522411134 Mailing 209 HOLIDAY RD APT Address: 322 Mailing CORALVILLE, IA City/State: 522411134 Date of 4/8/1978 Birth: None Sex: M Certified Abstract of Driving Record DL/ID #: 135AM0159 (IA) CDL Permit Class: None Class: D Audit #: 1363097 Issue Date: 10/13/2016 Expiration 04/08/2021 Date: Endorsements: 3 CDL Permit Issue None Date: CDL Permit None Expiration Date: Restriction None CDL Permit None Endorsements: CDL Permit CDL Permit None Restrictions: Iowa Department of Transportation ID Status: None Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Supplement: CDL Permit ELG Office of Driver Services Status: Iowa Department of Transportation CDL Cert Status: None CDL Med Status: None History Information CLEAR DRIVING RECORD Name: Kudoda, Ashraf Mohammedelhad DL/ID: 135AM0159 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: """•:MINVII 10/27/2016 IOWA ?'f o; D. 0. T.: �, 7f UB�VER S= Office of Driver Services Iowa Department of Transportation Name: Kudoda, Ashraf Mohammedelhad DL/ID: 135AM0159