HomeMy WebLinkAbout16-246rt.atf�_
CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa S2240-1826
(3 19) 356-5040
(3 19) 356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. ! b— -2-q LO
(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)S2f)r
3. Contact Information (REQUIRED) Email: I _e-,om Cell Phone: �K 19-5bm-2c3qcf
(All written communication sent via email)
4a. Driver's License expiration date (REQUIRED) 0/—,Z c/120 J7
b. Taxicab Business Name (REQUIRED) C h f � �h
I
5. Prior experience in transportation of passengers:
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
What happened to the charge? (Circle one)
Where
When
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
What happened to the charge? (Circle one)
Where
When
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? �(�S
Type of offense
Wher "
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9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please {ugvide 8 nam(s)
M
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED RE
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF VIEW
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
Ihereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
I
,rte n17 RS /7 issued on �/R�expiring on p/Z2JZ2o L7--. I understand that if 1
falsely answer any questions in this application, that this application may be denied. I agree that in making this application,
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 7Gtk 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by on this ark day of
in and for the State of Iowa
ll4HH+1f11+H+1H++-+++ilfHh�+ltRlf+,hl+f++lf+f�I+ltffltMt++R##i+1+++!llHH1#Hl+Yl+tl+HHit+lll+YfflMlH+It+f
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 ." ' raj%
Signature of Police Chief or designee
,1/T/�/6
o ' 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.
Sign re of City Clerk or designee
Date
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Office Use Only 1%'=
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Approved application
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DCI report
State certified driving record
Website update
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G�MIMIVBADGEAAPPLe201aa ded.DOC 07/2016
Froep.if. [oiovr+:tyrlvl,�aruly of t,rlminal i n v e s i l g a i l o n No. iUIU r.l/I
.. - -- ..-----1 08/08/2016 12,.S- wa,86 �.....2/Oo2
f STATE 01' ff OWA
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�' l�_..� rriminai Mstorry RecoW Check s ��
tel
"1' : I Request ]Form'
DQ Account Number; L(o d '2— 7—
(ifapplicable)
To: Iowa Division of Criminal Itivcscigation
Support Operations Bureau, 1" Floor
215 E. 71h Street
Des Moines, Iowa 50319
(515)925-6066
(515) 725-6080 F'ax
I ant reouestine an Iowa Criminal History Record Check nn,
From: City of Iowa City
City Clark's office --
410 P. Washington Strett
folva City, LA 52240
Phone; 319-356-8041
Fax: 319-356.5297
Last Name mandatory)
lie t Name (mandamry)
]Biddle frame (recommended)
C^
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Date of Birth (mandatory)
Gender ((mandalory)
Social Security Number (aadmme tded)
,a
MM/'ale Ob'emale o S 1— 76-S802,
Waiver rnformafton., Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code of lows, Chapter 692.2. For comnlece criminal history record Information, as allowed by law, always
obtain a waiver sl nature from the subject of the re uest.
Waiver Reie(Ue: l hcrebygnic permission for dmabove rcque Vg official to conducton loess criminal hislosyrecord check with the Division ofLriminal
Imre igetion (DC). My criminal hislory dale released as allowed ry Imr.
n
Waiver Signature;
l[oawa Criminal History Record Check Results
As of `— \ ,- -, a search of the provided name and date of birlh revealed;
No Iowa Criminal History Record found with DCT
Iowa Criminal History Record attached, DCl # i5
DCI initials ►v �'
DCI -77 (08/25/10)
Received Time Sep, 6. 2016 12:13PM No.3537
(D gse on(y)
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C4JIOWADOT
vvww.iowadotgov
SMARTER I SIMPLER I CUSTOMER DRIVEN
Inquiry
Date:
Customer
Name:
Address:
11/3/2016
4550505
Office of Driver Services
PO Box 9204 I Des Moines, IA 50306-9204
Phone: 515-244-91241800-532-11211 Fax: 515-239-1837
W Ww. iowadot-gov
Certified Abstract of Driving Record
DL/ID #: 152DD8517 (IA) CDL Permit Class: None
Class: D
Musa, Mutwakil Mohmed Audit #: 9348598
51 REGAL LN Issue Date: 08/18/2015
City/State: IOWA CIN, IA
522406765
Mailing 51 REGAL LN
Address:
Mailing IOWA CITY, IA
City/State: 522406765
Date of 1/29/1965
Birth:
Sex: M
Sanctions
Expiration 01/29/2017
Date:
Endorsements: 2
Restrictions: Corrective Lenses
Restriction None
Supplement:
History Information
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
None
CDL Permit
None
Endorsements:
Suspended
CDL Permit
None
Restrictions:
Non -Payment of Child Support
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit
ELG
Status:
Suspended
CDL Cert Status:
None
CDL Med Status: None
Type
Effective
End
ACD
Explanation
Occurrence IUR
3UR
Suspended
',08/02/2012
106/18/2013
D51
Non -Payment of Child Support
IA
IA
Suspended
108/25/2012
06/18/2013
,D51
INon-Payment of Child Support
IIA
IA
Name: Musa, Mutwakil Mohmed DL/ID: 152DD8517
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:
a•.
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.......I/�4. �i4i 11/3/2016
IOWA � ,
q�
'eelri� Office of Driver Services
�a.� ,�•�`� Iowa Department of Transportation - ••
DO
Name: Musa, Mutwakil Mohmed DL/ID: 152DD8517