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Home My WebLink About17-1287 Qr IDENTIFICATION NO. '/ / ll (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday— Friday) 410 East Washington Street Iowa City. Iowa 52240-1826 Failure to complete the `required" information will result in denial of the application (319) 3S6-5040 (319) 356-5497 FAX 1. Name (REQUIRED) First �ctM�r2)�tn.bja Middle �7Q} I Last Mo 2. Address (REQUIRED) 4-D 4,424P�41)4) T141'2 T Y 2`/A I/ 3. Contact Information (REQUIRED) Email: 4Wd;4fWg1. rAA JI'1 %�I4n_rA4A Cell Phone: LI7 z � (II written communication sent via email) 4a. Driver's License expiration date (REQUIRED) a/a I J I 6 b. Taxicab Business Name (REQUIRED)r/1 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? VCP< Tvoeofoffense Where When 45a11 't-0 v old C�1 64iO4e1/ :2 I� U What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested/ charged with any traffic offenses in the last five years? / . T Type of offense Where When A e r� What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Gu* —,Ott# 8. Has your driver's license or chauffeur's license been suspended or revoked in the last fivey -dos? • % _-� c, Type of offense Where E tem3 Ott 1 7,0 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) 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 q valid Driver's license number fl19nl3 issued onexpiring on a I understand that I I falsely ans er any questions in this application, that this app ica�y be denied. 1 agree t at 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 : �c� Date STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by mt1katon this i Z day of , v.Air -7,01 -7 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 C�i wa City (Title 5, Chapter 2, City Code). Exoiratioh date "vers lif ense 2Z21,( � Signature o POII e C ' 6Tdesignee a AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICA9M IOWA CITY! OR NO MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. 4 ' N SigrAture of City Clerk or#15signee� M17 Office Use Only Approved application DCI report State certified driving record Website update OeWTARIDRNBADGEAPPL9201"e ded.DDC 07/2016 CZ10WADOT SMARTER I SIMPLER I CUSTOMER DRIVEN WWW'IOWBCIOt.gOV Inquiry Date: Customer Name: Address: 9/12/2017 6082673 Office of Driver Services PO Box 9204 1 Des Moines, IA 50306-9204 Phone: 515-244-91241800-532-11211 Fax: 515-239-1837 www.iowadol gov Certified Abstract of Driving Record DL/ID #: 684AJ7013 (IA) CDL Permit Class: None Class: D Mohamed, Gamerelanbia Audit #: 1239348 Ismail 2608 BARTELT RD APT Issue Date: 08/18/2016 2D City/State: IOWA CITY, IA 522462730 Mailing 2608 BARTELT RD APT Address: 2D Mailing IOWA CITY, IA City/State: 522462730 Date of 1/1/1957 Birth: Sex: M Convictions Expiration 01/01/2018 Date: Endorsements: Chauffeur 3 CDL Permit Issue None Date: CDL Permit None Expiration Date: Restriction None CDL Permit None Endorsements: CDL Permit CDL Permit None Restrictions: Johnson ID Status: None Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Supplement: CDL Permit ELG Fail to Yield Right of Way Status: Johnson 39/20/2015 CDL Cert Status: None History Information CDL Med Status: None Citation Date Conviction Date ACD Explanation JUR County 33/01/2014 03/24/2014 N61 Fail to Yield Right of Way IA ra Johnson 39/20/2015 10/22/2015 M14 Fail to Obey Traffic Sign/Signal _ IA Johnson 32/18/2017 03/09/2017 N50 Improper Turn -�_A rn Johmn � Accidents - Accident involvement indicated does NOT mean the individual was at fauR-br4givn a cif =n. —1 C7 ' — tccident Date JUR Case Number- FT1 v _ s Q )2/18/2017 IA 970148 �� O N Name: Mohamed, Gamerelanbia Ismail DL/ID: 684AI7013 (IA) 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: L1 IOWA D. 0. T Name: Mohamed, Gamerelanbia Ismail Di_/ID: 684AJ7013 (IA) 9/12/2017 Office of Driver Services Iowa Department of Transportation y'1"ATE ter 10WA $a Criminal History Record Check d Request Form 46 7 DCl Aecuutil Number: —L�]�� To: 10198 Division or Criminal htvtstlgation Frmii: Citv of lova City Support Opera(tmts Blircou, I" Floor City Clerk's Office ---- 21S E. 7" 5irecl 410 !r. 1Yashin�lon ,S(recl Des Mohtes. Iowa 50319 --- (515) 725-6066 fov;a Colt, rA 52240 o) .12-4020 Fay, ['hone: 319-356.5041 rax: 319-3565497 I am reauestinn nn Tnwa C iminal Mie/ro., u,.,.,..a Pl,.M, Last Name (mandatary) First Fame (n, aaaatory) 201119 4:0.,, riet'e.Ta.�la of Criminal Investigation Social Securi Number (feeommendad) P. -Elk—ale ❑F'ewale ,7 Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not �ie,rDiv obtain a waiver signature from the subject of the request. Wayer.Release• l hereby tivepermision fprme,�nverem�yap�Ne:atJars dyGanJyvysyr,,inaud:lasysceel'dehedrwitlnbr5ivisinrrofCrinmRl-- I11vesligetion (DCI). Any criminal history dale co/neemmIng--n��it that is mainlained by the DCI maybe released as allowed by law. 06/06/20,7 ,0:No.0357214 Waiver staolt[[lr!re: .2/2/002 y'1"ATE ter 10WA $a Criminal History Record Check d Request Form 46 7 DCl Aecuutil Number: —L�]�� To: 10198 Division or Criminal htvtstlgation Frmii: Citv of lova City Support Opera(tmts Blircou, I" Floor City Clerk's Office ---- 21S E. 7" 5irecl 410 !r. 1Yashin�lon ,S(recl Des Mohtes. Iowa 50319 --- (515) 725-6066 fov;a Colt, rA 52240 o) .12-4020 Fay, ['hone: 319-356.5041 rax: 319-3565497 I am reauestinn nn Tnwa C iminal Mie/ro., u,.,.,..a Pl,.M, Last Name (mandatary) First Fame (n, aaaatory) Middle Name (reeammended) o e� riet'e.Ta.�la I S q; Date of Birth (mandamry) Gender (mandatory) Social Securi Number (feeommendad) o1 �I � S -Elk—ale ❑F'ewale Z p o 5S3 Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record Information, as allowed by law, alnays obtain a waiver signature from the subject of the request. Wayer.Release• l hereby tivepermision fprme,�nverem�yap�Ne:atJars dyGanJyvysyr,,inaud:lasysceel'dehedrwitlnbr5ivisinrrofCrinmRl-- I11vesligetion (DCI). Any criminal history dale co/neemmIng--n��it that is mainlained by the DCI maybe released as allowed by law. Waiver staolt[[lr!re: Toga Criminal History Record Check Results tflClraedtl7P nn n As of "1 _ a search of the provided name and date of birth revealed: • r b rn 3 No Iowa Cruninal History Record found with DCI ❑ Iowa Criminal History Record attached, DCI # I, DCI initials IJG1-/ I (US/25/IU) Received Time Sep. 5. 2017 9:50AM No.6125