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Home My WebLink About17-092�_ lull CITY OF IOWA CITY 410 East Washington Streel Iowa City. Iowa 5 2240-1 82 6 (319) 356-SO40 (319) 356-5497 FAX 1. Name (REQUIRED) 2. Address (REQUIRED) IDENTIFICATION NO. I-7-0C1Z (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: written com 4a. Driver's License expiration date (REQUIRED) q a 1 b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: email) 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? a0 Type of offense What happened to the charge? (Circle one) Where Convicted Dismissed Deferred Suspended Plead 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 Convicted Dismissed Deferred When Oth�\L_ 7 C r Suspended Plead Guilty Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Type 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) n( 0 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 1 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 1 I hereby �certify t j,.,l�l7�ve issued to me by the Iowa Department of Transportation a v lid Driver's license number iL JS issued on 4 expiring on I understand that if I fats answer any questions in this application, that this application may be denied. I agree that in aking 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 Date •.H...,.,,a:...r.:.rN.k..r.,,,,:.:....r....,,..,:,:....H...,:.,+...:r....H.«,+.+,:.r...:r......,.e,m.�...++,r.,r,.........+r�,.w.++..... STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by 1 ► l0 �LLYYt �� T k1Y'CC N) Yy'\ on this . day of 201-7. KELLIE K. FRUEHUNG . ._e-. o t Con.ni.eion_N~, "'O otaryublic in and for th tate of Iowa 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 �/ ZZZA Signature of Police Chief or designee DateDate 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. l� L t/CILPI Signature of City Clerk r designee 7-13--17 Date OarkrrAXIORN84DGEAPPL92014amendW.DOC 07/2016 oC= Office Use Only o _ —' C_ D rr Approved application w DCI report -r m State certified driving record Website :5" = Q update g N D � • OarkrrAXIORN84DGEAPPL92014amendW.DOC 07/2016 I .-.. ii i ..... .... ..1 -1 i.ni1.. .n.ate,.11,1— From:Cl1y Of Iowa Olry Clerk Of(]-- 219 aee6e407 11. 11 IV I/ 1 07/06/2017 11:64 n101 P.002/002 STATE OF IOWA 1• ;j \'i Criminal History Record Check Request Form DCl Account Nunibor-r (If appnienblo To: Iowa Division ofC-imina)investigation Fron: City ofIow_a_Cily _ Support Operations Bureau, In Floor City Clerk's OfQte -� 215 P, 7'h Street 410 £, Washington Street _ Des Wines, Iowa 50319 f51�'79.a-an A raws, r1W r,s e��0 (5)5)725-6000 Fax Phone: 319-356-5041 Fax: 319-356-5497 Last Name (ntanda(a ) First Naine (nsandatory) Middle Dame (recommended) Date of Birth (mandatory) Gender (mndmory) Social Security Number (recommended) Iq ❑Male ❑Female ? I" 5 ;� % `I Waiver Information., Without a signed waiver from tine subject of the request, a complete criminal history rote rd may not be releasable, per Code of Iowa, Chapter 692.2. Por complete criminal bistory record Information, as allowed by low, always obtalrawaiversi ana fare fro inthesuh' cot OfEli ere vast. Wal ver Role se: l hcaby give pemsission for the above rcqucssing officisI to condvol an Iowa crimiosl hislory record check. with Use Division ofccimiml tnwenigelion (DCI). Any triminol history data concerllinglne Ihal Is maintained by the DCI may be released as allowed by law. i1<rafVC!' .Sl; IrafaMC: _ LQ�t Iowa Criminal History Record Check Results I (ccluseonly) As of O� 1� T, a search of the provided name and date of birth revealed: No Iowa Criminal History Record found with DCI ® Iowa Criminal History Record attached, DC1 # �. F5 DCI initials "i - DCI -77 (06/25/10) Received Time Jul_ 5. 9017 11 90ANI No.9440 Customer History OCertified Driving Record dCourt Certified Driving Record C3Lbst oyer and DUID Information [History Events Only ❑Internal Complete Driver History (Non-Certlfled Driving Record QJ10WA00Twwwiowadotgov SMARTER I SIMPLER I CUSTOMER DRIVEN Explanations Medical Examiner Hrst Name am" at Droner Services Medical Examiner Middle Name _ PO Boz 92M 1 Des Mclnes. a 503080204 Phone'515244-91241800-532-1121 I Fax: 515-219-783] _ Medical Examiner Liteme Number www.aaadot gov Certified Abstract of Driving Record Inquiry Date: 7/13/2017 DL/ID#: 257DD6818(W) Customer g: 4350508 Class: A Name: Ibrahim, Mohamed Elsadlg Audit #: 1399749 Address: 2504 BARTELT RD APT 2B Issue Date: 10/28/2016 Expiration Date: 09/02/2019 City/State: IOWA CITY, IA 522462714 Endorsements: NONE Mailing 2504 BARTELT RD APT 2B Restrictions: NONE Address: Restriction None Mailing IOWA CITY, IA 522462714 Supplement: City/state: Date of Birth: 9/2/1979 Sex: M CDL Medical Examiner's Certificate CDL Permit Class: None COL Permit Issue None Date: CDL Permit None Expiration Date: CDL Permit None Endorsements: CDL Permit None Restrictions: ID Status: EXP DL Status: VAL CDL Status: VAL CDL Permit Status: ELG CDL Cert Status: Non -Excepted Interstate CDL Med Status: Certified Certificate Specifics Explanations Medical Examiner Hrst Name - ___ lames _ Medical Examiner Middle Name _ _ W __ _ _ MedicalExaminerlartName Mliani _ Medical Examiner Liteme Number _ ohnson Medical Examiner National Registry Number_X9399145280 )9/29/2012 Medical Examiner Jurisdiction_ IA _ IA _(319)]68-4151 _ Medical Examiner Phone _ Doctor_ 11/16/2016 _ Medical ExaminerType _ Medical Certificate Issued Date Medical Certificate Explredon Date _IIA _ Date Added to CDLIS Driving Record _ ,11/12/2015 History Information Convictions :nation Data Conviction Date ACD Explanation County JUR )5/38/2012 _ 108/2-/2012 _ 592 (Speed _ _ _ ohnson _ _ IA )9/29/2012 11/06/2012 /2 S92 _ Speetl _ b.hnson _ _ _,IA --- LI/2 ]/2013 _ 12/04/2013 M]0 Improper Passing Drrohnson _ _IIA _ 10/10/2015 _ ,11/12/2015 _ Defective Lights I'ohmon :IA Name: Ibrahim, Mohamed Elsadlg DL/ID: 257DD6818 Pursuant to Iowa Code 4321.10, 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 (Mice of Driver Services, that this Is a nue and accurate copy of an official record currently in the custody of said once, and that 1 have been authorized by the Director of the Iowa Department or 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: Name: Ibrahim, Mohamed Elsadig DL/ID: 257DD6-1B ttV.,+w��o IOWA D 0. T ]/13/201] ly,�taed %j'f'fl Driver Services Iowa Department MTrensportatlen Imo a Name: Ibrahim, Mohamed Elsadig DL/ID: 257DD6-1B