HomeMy WebLinkAbout17-120f�
r t
7h �III�
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. Ji Z�
(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
3. Contact Information (REQUIRED) Email: 00 mW Cell Phone:
(Allwn mmCell S4qj
i
4a. Driver's License expiration date (REQUIRED) 6 lI 6 tT!Q 0 7_ti-
�cb. Taxicab Business Name (REQUIRED) ` - r -M LA
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? IN/0-
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? YE;�
Type of offense
Where
When
1 C,) r 1 �t/Z
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? 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, please e t9nameM
n'G W
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATEZERTWIED I'j'I
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE:CWF REVIEW,
-77 '-a
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
cT
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
herebyy certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
�Q2L1 }� (7_ issued on 'expiring on I understand that if I
falsely answer any questions in this application, that this apple ton may be denied. I gree '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 D) Date o Q/ fir/ 201
STATE OF IOWA )
COUNTY OF JOHNSON ) `
$ubscribedlI and sworn to before me by ��kzr P.o• o,��o�ngMreo J�oo this 3V day of
♦++e+rm».»x.mre»»»a..»...ew.r..r..e�.a.»+.e+..m»....x»xxeeeree.»».»+....er�yem...a............rr�»..»....yy»y.».»e..:e..
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 d er errs lice se
— V 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.
0/30/17Siggbture of City Clerk designee Date
CIe, ffMID NBV GEAPPL92014ame dWDOC 07/2016
Office Use Only
o
�
–n
1
Approved application
n "�
G-)
DCI report
yn
o
1--
State certified driving record
fir'
Website update
CIe, ffMID NBV GEAPPL92014ame dWDOC 07/2016
FreH..u.g. 29.. _201_/ 3_2.5YIN,, orkUly of Criminal lnvestigatioo No. 5641 P. /2
r ..� � 0Oa/2./2017 16:3_ X196 ,_1mac/002
a
STATE OF i(®WA
Crriimmlinal History Recgd Check
Request (Form
To; Iowa IDivision of Criminal Investigation
Support Operations lituresu, In Floor
215 E. 7d' Street
(513) 725-6066
(415)125-6090 Fax
I aul l'Caucclina an Tnwa Criminal Hietnro Rnnn.d tll-1....,•
-
DCl Account Number:. tieoZ�i-
(if applicable) —
From: Citv of Iowa Cit
City Cleric's Office
_ 410 B. Washington Street
Iowa City, IA 52240
Phone; 319-356.5041
Fax. 319-356.5497
L� �- a5f N? ajne (mandalory)
I FirSt Natfle huandalcry) Middle Name irccoNmrnded)
ohamainkero\
v>m" vS�cL
Gender (nlandalary Social Securi Number (recommended)
Date of Birth (mandatory)
Gtr v1' N90
As of t� a search of the provided name and date of birth revealed;
WWWVer Xiifovnersti0n: Without a sighed waiver from the subject of the request, a complete criminal history record may not
be releesoble, per Code of Iowa, Chapter 692.2. nor eombete criminal history record information, as allowed bylaw, always
obtain a waiver signature from theSub-t:cl t of the request.
T17aiver Release: l hertbygivepermission for Ille above requesting official to conduct" Imva criminol history record check with the Division ofCriminnl
Invesltaation (DCI). Any criminal bismry dura concealing nie dial is mainlaincd by 1119 nCl may bo relemed as allowed bylaw.
WaiVgr S'ignatlU'e: ,.
I<oa�a Ctilllin�l �isto� >lgecort>i Check ][8esufts
(Del use oldy)
As of t� a search of the provided name and date of birth revealed;
1\10 Iowa Criminal History Record found with DCT
v
Wr
® 10M Criminal History Record attached, DCT #
rrn 3
DCT initials_4
—
co
DCI -77 (08225/10)
Received Time Aug 24, 2017 4:13PN No -5521
LIowa Department of Transportation
�ce or Dfaer Services (Tall Flee) 900-5M-1121
PO Box 92114, Des MoinCtS, IA bi 02O4 515-244-9124
FAX 515-239.1831
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
8/30/2017
DL/ID #:
582AH0582(IA)
Customer #:
5930422
Name:
Mohammed, Nasr
Class:
D
ID Status:
None
Aldden Osman
Oshar
Address:
2610 BARTELT RD
Audit #:
1497824
DL Status:
VAL
APT 2C
Issue Date:
12/17/2016
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration Date:
01/01/2025
CDL Cert Status:
None
522462731
Endorsements:
Chauffeur 3
CDL Med Status:
None
Mailing Address:
2610 BARTELT RD
Restrictions:
NONE
Restriction
None
APT 2C
Supplement:
Date of Birth:
01/01/1980
Mailing
IOWA CITY, IA
Sex:
M
City/State:
522462731
History Information
Convictions
Citation Date
Conviction Date
ACD
I Ex lanation Co i nty
JUR
01/25/2015
02/12/2015
M70
Improper Passing Johnson
IA
Name: Mohammed, Nasr Aldden Osman Oshar DL/ID: 582AH0582
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: ..
rU
4M 8/30/2017 0
IOWA
D. 0.1,,'a �J
•y Office of Driver Services
Iowa Department of Transporatio7