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HomeMy WebLinkAbout17-131 IDENTIFICATION NO. / 7— I t (Office Use Only) iii ft. me grar 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) 356-5040 (319) 356-5497 FAX First Middle Last r 1. Name(REQUIRED) 1 C,�C1 yY 1 �� �y) C‘7Jvp {of AJ 2. Address (REQUIRED) 2-1_3 17 pisP L 1 L � AT co/s/ c.;- y 5224,6 3. Contact Information (REQUIRED) Email: Cell Phone: 7c --29.6 949 (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) j o /n 6 b. Taxicab Business Name(REQUIRED)Jr w ct.Y\ i 5. Prior experience in transportation of passengers: Ye_5 6. Have you ever been arrested/charged with any misdemeanors and/or felonies in this State or elsewhere? 1 v 0 Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other \/' 12, 7. Have you been arrested/charged with any traffic offenses in the last five years? Type of offense Where When 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 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please,'pokvide the name(s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STy. EIf'NFIEC DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLI IEF{�EVIf 1You must apply for an individual Department of Criminal Investigation Report (form avaifable:ppon re—crest). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 07/2016 INF APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number 2.t 2 -A A158 o5 issued on o`t-o&,.)expiring on \D. (1,6.-f7 . I understand that if falsely answer any questions in this application, that this application 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 provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant 's Date ©l--1 S-O *********}t!}}*#*}*##********************}#!##*#*}}}********A A A AA AAAA****tt**********t*****************Kt*****#•#t****t******}**}*************** STATE OF IOWA COUNTY OF JOHNSON ) I ,, Subscribed and sworn to before me by (4� � lo.nQ Zvi . Mou`cc. on this [ S" day of Zol-1 . . 1 A. Notary Publics and for the State f Iowa VGAPNIIIIIMOP hitiraw *******• ***********k***************************************** *************tk******AA A AAAA*******************AAAMAA***** 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 Ci .f Iowa Ci Title 5, Chapter 2, City Code). Expira•on d- - o i river'- license l II / Lr 17 Signature ,.f Police hief or designee 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. 9/12/ 7 Si nature of City Cler r designee ate *****}A AAAA A A At**** *********A*..wr***********}}********************}H}*******t*****************}#AA...A A AMt**tt******************}}} Office Use Only LJ �• Approved application � --+ `0 -_.. s DCI report C° r.... State certified driving record n Website update M CleFWTAXIDRIVBADGEAPPL92014amended.DOC 07/2016 ARTS Page 1 of 2 Clib' OVVA D 0 T SMARTER I SIMPLER I CUSTOMER DRIVEN www.lowadot.gov Office of Driver Services PO Box 9204 I Des Moines,IA 50306-9204 Phone:515-244-9124 i 800-532-1121 I Fax:515-239-1837 www.00wadol.gov Certified Abstract of Driving Record Inquiry 9/15/2017 DL/ID #: 212AN5805 (IA) CDL Permit Class: None Date: Customer 6655900 Class: D CDL Permit Issue None #: Date: Name: Nourain, Hamad Audit#: 2125805 CDL Permit None Mohamed Expiration Date: Address: 2417 PETSEL PL APT 3 Issue Date: 09/06/2017 CDL Permit None Endorsements: Expiration 01/01/2025 CDL Permit None Date: Restrictions: City/State: IOWA CITY, IA Endorsements: Chauffeur 3 ID Status: None 522463609 Mailing 2417 PETSEL PL APT 3 Restrictions: Corrective Lenses DL Status: VAL Address: Restriction None CDL Status: None Mailing IOWA CITY, IA Supplement: CDL Permit ELG City/State: 522463609 Status: Date of 1/1/1969 CDL Cert Status: None Birth: Sex: M CDL Med Status: None History Information CLEAR DRIVING RECORD Name: Nourain, Hamad Mohamed DL/ID: 212AN5805 (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: `®�`••''••''•.4u4I 9/15/2017 tw:: IOWAtr a U .a: * ,II &4t**** % r Office of Driver Services o Iowa Department of Transportation CDCr, > !z� �'l Name: Nourain, Hamad Mohamed DL/ID: 212AN5805 (IA) —if') CO r f" • 1 -zsz ED yy 9/15/2017 http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx j' AR I S Page 2 OI 2 i=cy zJ 7"C _. C co Cr1 http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 9/15/2017 F, ep. 11. 101l,,IU; Ui MC1e1Uly o? lriminal Investigation afl,Q72o„ ,6 No. U5/61,2y,I 1/12002 • • • fi `J rCriminal History Record Cr _ °1WA DCI AcoAuni Number; . _.. .. - . . - - • - - . - - -- ? .- (if ARIL:able) To: Iowa [ivisiun of Criminal Investigation From; City of Iowa Cit}' Support Operafiolls Bureau, I” L loor City Clerk's Office ^' `— 2I5 E.7'"Street 420 E.\Washinuton Street Des Moines,Iowa 50319 __ _ (515)725-6066 (515)725-6080 Fax rill!, r� 4290 :__ , Phone: 3X9-356-5041 Fax: 3119-356 5497 ------------- I am reuestiug an Iowa Criminal History Record Check on: Last Name (tnandatc ) • First Name(mands�ory) 'Middle Name(reeommenderl) aou ''n - ND(r,VLri.li ViCA vwi c CI On On o\,f, a oieri Date of Birth (mandaioq') Gender(mandatory) Social Security Number (recommended) — r\G\ 64- Tale OFelnsle , i. n ) OJ ( _ 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,always obtain a waiver signature from the subject of the regest. ____Wailho?RPlea T i,tabysive-pe.rinission.femile•ebove anqAg-ofjeiolio-tondtn,'raniora 1,rlmlttallt3lory record chid;with the Division of Criminal Investigation(DCI). Any criminal histoy dela concerning me that is maintained by the DCI maybe released as allowed by lav, WaiverSianature: • °�/" � /(1/�( �y 1L - Ia_ ra Cr rain if Ristnror Iiiec.o~c$ Cheek Results (� l r/ .(' (DCI use only) As of a search of the provided name and date of birth revetiteie. cn qnl r No Iowa Criminal History Record found with DCI : 0 Iowa Criminal History Record'attached, DCI# __ :fr. DCI initials C-C---, DCI-77 (08/25/10) Received Time Sep, 1. 201? 2:48PM No. 6380