HomeMy WebLinkAbout17-122f
CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 356-5040
(319) 3S6-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED)
IDENTIFICATION NO. 17 Jz-�(
(Office Use Only)
APPLICATION FOR TAXICAB i 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:
$a
(All written communication
4a. Driver's License expiration date (REQUIRED)
V—)
Last
)Wa Li L) ,tit �22-Zq
L Cell Phone:
b. Taxicab Business Name (REQUIRED) \+1 fW\ A%(1 C R
5. Prior experience in transportation of passengers:�/_ � 'fiG >C I V) 9 Aq
11
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Q
Type of offense Where When
What happened to the charge? (Circle one) ra
0
Convicted Dismissed Deferred Suspended Plead Guilt Othw
C/)
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense Where n—*eri r
What happened to the charge? (Circle one) r?
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? 0
Type of offense Where When
9. Have you ever appl' d 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
1
l
..f
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
hereby ert'' that I have issued to me by the Iowa Dep ment of Transportati n valid Driver's license number
U C0 9 �� issued on o�expiring on a 2 0 3. I understand that f I
fal ely answer any ques ions in this application, that this application may be denied. I a6red that in making this application, I
consent to allow agents or employees of the City of Iowa City, Iowa, in their discretion, to examine a�, ,,y and all records and
documents relating to this application, and I further agree that, if authorization to be a taxicab driver ismanted, to comply at all
times with all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in i nt ofootafMblic)
9
Signature of Applicant Date L O
� l
C frit Z
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by a r4\ S hSrA on this day of
)lic in and for the Shite 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 06 • / 7 • ?x+13
Signature of P ce Chief or designee
0/•2+17
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 ture of City Clerk designee Date
Office Use Only
Approved application
DCI report
State certified driving record
Website update
GarWrAXIDR1VB4DGEAPPL92014am ed DOC 07/2016
Page 1 of 2
ClJOWADOT
SMARTER 151MFLER I CUSTOMER DRIVEN
vwvw,lowadotgov
Office of Driver Services
PO Box 9204 I Des Moines, IAS 50306-9204
Phone. 515-244-9124 1800-532-11211 Fax:;515-239-1837
www.IU"dot-gov
Certified Abstract of Driving Record
Inquiry 8/30/201.7 DL/ID #: 450AF6378 (IA) CDL Permit Class: None
Date:
Customer 5729103 Class: D CDL Permit Issue None
#: Date:
Name: Sharif, Mi hamed All Audit #: 9336298 CDL Permit None
Expiration Date:
Address: 2413 SHADY GLEN CT Issue Date: 08/13/2015 CDL Permit None
Endorsements:
Expiration 08/17/2023 CDL Permit None
Date: Restrictions:
City/State: IOWA C , IA Endorsements: Chauffeur 2 ID Status: None
52246415
Mailing 2413 SH, DY GLEN CT Restrictions: NONE DL Status: VAL
Address: Restriction None CDL Status: None
Mailing IOWA CI , IA Supplement: CDL Permit ELG
City/State: 522464111115 Status:
Date of 8/17/1978 CDL Cert Status: None
Birth:
Sex: M CDL Med Status: None
i
History Information
Convictions
I
Citation Date Conviction Date ACD Explanation JUR County
12/07/201301/22/2014 592 Speed IA Johnson
Name: Sharif, Mohamed All DL/ID: 450AF6378 (IA)
Pursuant to Iowa Code l§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:
"•2?�,'4rr 8/30/2017
IOWA
D. 0. T.e9g
Office of Driver Services
.�� Iowa Department of Transportation
8/30/2017
Aug.31,
2011 3:22PM
Div of Criminal Investigation
No.9614 l'. 1/1
Pr.,,:CI1y
of Iowa CI1y 01 90; 3l® 36ffs,lul
08/31/2017 14!21 .212 r•.UuG/002
' Aug. 31.
2011 1;04 PM
Div of Criminal lnvesligation
No. 9756 P. 2/3
Crcm!C,ly
of Iowa CIIV
Clbrl' Clflcu 319 -�OGG4137
60/30/mol-, 13:^00 620G P.002r002
STA N,, OF MTV ov.
11if„�a y Pkeoid Uma")v�ef�uekt rfanfli 'oh
DOIApo0witNUlnher: ... J%?G'
tti
7'U: Ill14a 1)IPIYIUII of (:I'1 Ull1101 Pll vestloa tlUa Fron: _(:Ily Of 101'12 City
4npport4perallunsRnrcael i11rlGar y— —' .--
2I51 7"' S'(roGf Ci(y CtetlPc Offie(
5) 725.6066
ml:
1110111 319.356-5045
• �. - .. ...�,� smraa pecomn1a10o61
(�61v I M
C L L G✓� �. In
Qv �
7)hte of Eh'th imnmzlmY)
Gender (aundaloly) ROW Sc^ e(//y Nup h r (retommerl
G ( ",> 4cvlY[ de ❑i7emale G �' �j % yJ �L 2—
I'I/nlVOI'.(1(fOrrfUQfOp: \gltho'it a signed waive• )'ODI the subJeet ojthe regtiest, a eornptme erin)Ino) hlstary rceord troy not
be releasable, per Code of 1011-0, Chapter 692.2. d'Or com ate 011/1111341 hi0ory record information, as allowed by law, Always
OUtaln a waiver slt!11O(ure from Ih a sub cc( of fhe request,
I4rR/VerREfe+RSe;.1.btmLYtiweyarmktlon�oH6eshovareoaetan.. ,El omn u4 �-
t M�bnrelesedm linowedeeefd Tllrtt; x111 e1:DiviSiV�o7 (.'11131113111
oa'aSit��tP3T(DL))-'Any'd re naf�laery Dale eonr+ultins mr Nel is maimalnW by ilia DCI mey 6erelexseu u ollolvea by loot
WaiverSlffRniare:
•tPol life anlyl
As of a search of the. provided name al)d date of birth revealed;
. NO IDwa Criminal Histniy Record found with DCT ,
❑ Iowa Criminal History Record att;161W, DCI # __
DCI injtials^
MI -77 (0 9/251111)
RecerirvevdlTimerAusr3lt. 2011 9:04 (;0,5(1021
Page 2 of 2
Name: Sharif, Mohamed All DL/ID: 450AF6378 (IA)
I
8/30/2017