HomeMy WebLinkAbout17-121J �
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319)356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO. )I, - t2-1
(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: KC C,K MD2_ 4�q� (yl 9B 5'12-Z4 OZS
(All written communication sent -via email)
4a. Driver's License expiration date (REQUIRED) U — O) - r Z O
b. Taxicab Business Name (REQUIRED) )n W a V\
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? D
Type of offense Where When
What happened to the charge? (Circle one)
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 Where When
-7 t l2 Z76 1 /Ifs 2-C IZ
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What happened to the charge? (Circle one)
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? P12 Q
Type of offense Where When
9. Have you ever applied to be an lowa,({[ity taxi driver using a different name? If yes, please
�p/r�nxide�thdMame(s)
Ve� AlfI1`t U!A 0 �� R ��\ � IJ 1'G y ;I'; w
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAT��.�,}�2TIWED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE = tT" REVIEJ'
You must apply for an individual Department of Criminal Investigation Report (form ava1121# upzn recV j).
y
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)' o
1
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa De artent of Transportation a valid Driver's license number
y � F % ? ? issued on o 2\ xpiring on of—o )- Zo2� 1 understand that if I
falsely answer ny uestioris in this application, that this applidation 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 provisioner TttleS,,Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date Z 2n, 2 (�
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by�/ �c�t < {h. Rlr on this S day of
NRNDY i�114YtRQ
t _ � Not-ary Public in (4nd for the State of I -u.
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 CAY'olowa City(Title 5, Chapter 2, City Code).
of
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Dat
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.
i � �— , �� --, e C,
—SignAure of City Clerk br Isignee
B 3/ /1-7
Datib
Website update
OeMff XIDRIVWGEAPPL92014amende .DOC 07/2016
Office Use Only 0-4
Approved application p�
DCI report SGS
State certified driving record
0
Website update
OeMff XIDRIVWGEAPPL92014amende .DOC 07/2016
C10WADOT
5M I www.iowadot.gov
SMARTER SIMPLER I CUSTOMER DRIVEN
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone- 515-244-9124 1800-532-1121 1 Fax: 515-239-1837
www.lowadot.gov
Certified Abstract of Driving Record
Inquiry Date:
8/24/2017
DL/ID #:
463AF2313 (IA)
CDL Permit Class:
None
Customer #:
5747667
Class:
D
CDL Permit Issue
None
Date:
Name:
Ali, Magdi Abdelmageed
Audit #:
9103552
CDL Permit
None
Mohamed
Expiration Date:
Address:
638 WESTGATE ST APT 45
Issue Date:
05/21/2015
CDL Permit
None
Endorsements:
Expiration Date:
01/01/2020
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522464636
Endorsements:
Chauffeur3
ID Status:
None
Mailing
638 WESTGATE ST APT 45
Restrictions:
NONE
DL Status:
VAL
Address:
Restriction
None
CDL Status:
None
Mailing
IOWA CITY, IA 522464636
Supplement:
CDL Permit Status:
ELG
City/State:
Date of Birth:
1/1/1980
CDL Cert Status:
None
Sex:
M
CDL Med Status:
None
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date JUR Case Number
12/18/2012 IA 717412
04/30/2016 IA 918607
Name: Ali, Magdi Abdelmageed Mohamed DL/ID: 463AF2313 (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:
IOWA
). 0. T.
Name: Ali, Magdi Abdelmageed Mohamed DL/ID: 463AF2313 (IA)
8/24/2017
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c
Office of Driver Services �a �l
Department of Transportation ":
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rIowa
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State of Iowa
Division of Criminal Investigation
215 E. 7" Street
Des Moines, Iowa 50319
Phone: 515/725-6066 Fax: 515/725-6080
Iowa Criminal History Record Check
Walk -In RPn11PSt
Your name: k
Address: 12 3,9 Wes
City/State/Zip: w! j
Phone #:
Requesting an Iowa criminal history record check on:
Fill in all shaded areas.
Last Name Apenido (mandatory)
First Name Primer Nombre (mandatory)
Middle Name Segundo Nombre (recommended)
�
MA67p f
AB�El.MC nMo4�Ar�
Date of Birth Fecha Nacimientto�(mnanddatory)
Gender Genero(mandatory) - - _..
Social Security Number/(r(rwommended)
1_ O' — -1 C� V
_
Male ❑ Female
34 3— b— J Z 1-
7 -Waiver Signaturf–F—IM-3-zKoe request is on yourself, please sign. If the request is on someone else, write N/A.)
Results
As of 6 I
i�No record found
, a name and date of birth check revealed:
❑ Record attached DCI #
DCI initials 1sc_
Receipt
DCI LSI- nN[.Y
_
m
Number of requests x $ 15.00 per last name =Total amount $ ($: t:70.
Method of payment: cash money order check # Q W 1FisterGaul or Visa
"t4did6T
Cardholder's name Mao,&, A 1; <a 1M,
m
- DCI initials
- - -- ---------------------------------------------- ----------------------------- ----� - - ----------
Credit Card #
DCI -83 (09/09/ 10; Revised 10/ 1/ 10; form reviewed 08/ 11/14)
Exp. Date