HomeMy WebLinkAbout17-095CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa S2240-1826
(319) 356-5040
(3 19) 356-5497 FAX
1. Name (REQUIRED) _
IDENTIFICATION NO. J ::� . ' ! _
(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
Middle
2. Address (REQUIRED) 31S E!5 SL aDl:.k U Off .rrdA/a
3. Contact Information (REQUIRED) Email: �lurt�en c munGa. h sent Cell Phone: �I'i— 57/`,— SJ3VV .
(All written communicaf sent via email)
4a. Driver's License expiration date (REQUIRED) 01A) ) j20 19
b. Taxicab Business Name (REQUIRED) To 1/11
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
Convicted Dismissed Deferred Suspended Plead Guilty
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
Other NO
When
Convicted Dismissed Deferred Suspended Plead Guilty Other )K\L
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? "o
Type of offense
Where
When
0
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, plea0$a)vi
C,5-< tV
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STA5 CES
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLI HIEW
You must apply for an individual Department of Criminal Investigation Report (form dNailablem
we
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
I
nal (s)
101
115
i request).
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
I I �K 60yI) issued on i `0/6 expiring on aj/n/lgol j 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 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant a� Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by `tt e PFS M . MT_kA_ Ogn this 2 day of
)urr Lb/ -) .
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 th Ity Iowa C(Title 5, Chapter 2, City Code).
license�J /
�/ZPII
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.
7 hf
Signature of City Clef fir designee Date
Office Use Only
Approved application
`
DCI report
p
State certified driving record
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Website update
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OerkrrAXIDRNBADGEAPPL92014amended.DDC
07/2016
vvi• L/, cvir ll.vunm ulv of t,riminai investigation No -3431 P. 1/1
From:Crly 0f levee Clly Cloek Clrlcn SIA SSeS497 07/21/2017 1x;27 #120 p,002/002
criminal History Record Cheek
Request Form
DCI Aocounl Number: —1!on
' , Ofapplitnble)
To: Iowa Division of Criminallnvestigation From: CityoflowacK
Support Operations Rureao, Ial Floor City Clerh's Of(iee
215 E.m ?"Street 410 I_. Washington Street
Des Moines, Iowa $U3I9
(515) 725.6066_ low a Citv IA sa2an
(515) 725 6000 Foy
Yhoitc: 319-356-5041
FaYr 319-356-5497 —
❑Female
waiver Lniormatteic without a sigued waiver from the subject of the request, s complete criminal hislnry record may not
bo releasable, per Code of Iowa, Chapter 692.2. F'or complete crilitinal history record mplete tion, as allowed re fart•, always
obtain a waiver si nature from the sllblect of the reano ei
1f?a1VCr—Re1et1Se: I hereby give pemlission forlhe above requeniog official to cnnducl an Iowa crimhtal history ncordrobeG: uiWthe Division of Criminal
Ineesligetion (DCI). Any cylmfnel 1115iory dale coneeming nm that is mafnlsined byihe DCl maybe (cleased as allowed by law,
N/RYverSig atuee;
Iowa Criminal History Record Cheek Results
As of —�l 'Cpjc�_,)- I1 a search of the provided name and date of birth revealed:
Ar
No Iowa Criminal History Record foutd with DCI
❑ Iowa Criminal History Record attached, DCII_.
F
DCT initials_
DCI -77 (08/2sn0)
Received Time ju1.91. 9017 9:09PM No.3309
(]Vose only)
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A001 NA DOT
www.lowado ov
SMARTER I SIMPLER I CUSTOMER DRIVEN g
Inquiry
7/21/2017
Date:
525013049
Customer
6231198
Birth:
�
Name:
Mohamed, Elwaleed
Restrictions:
Mussa
Address:
315 E 4TH ST APT 20
City/State:
OTTUMWA, IA
CDL Cert Status:
525013049
Mailing
315 E 4TH ST APT 20
Address:
Mailing
OTTUMWA, IA
City/State:
525013049
Date of
1/1/1975
Birth:
�
Sex:
M
Page 1 of 2
Office of Driver Services
PO Box 9204 ( Des Moines, Ui 50306-9204
Phone: 515-244-9124 1800-532-11211 Fax: 515-239-1837
www.lowadot.gov
Certified Abstract of Driving Record
DL/ID #: 815AK6090 (IA) CDL Permit Class: None
Class: D
Audit #: 1452952
Issue Date: 11/23/2016
Expiration 01/01/2019
Date:
Endorsements: 3
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Restriction None
CDL Permit
None
Endorsements:
�
CDL Permit
None
Restrictions:
ELG
ID Status:
None
Restrictions: NONE
DL Status:
VAL
Restriction None
CDL Status:
None
Supplement:
�
CDL Permit
ELG
,h®F•99111EA Si=r
Status:
co
CDL Cert Status:
None
CDL Med Status:
None
History Information
CLEAR DRIVING RECORD
Name: Mohamed, Elwaleed Mussa DL/ID: 815AK6090
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:
tlW1�4 4\`11
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7/21/2037
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>�: IOWA •z'a
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,h®F•99111EA Si=r
Office of Driver Services
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Iowa Department of Transportatiedr-
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a
Name: Mohamed, Elwaleed Mussa DL/ID: 81SAK6090
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7/21/2017