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HomeMy WebLinkAbout17-132 IDENTIFICATION NO. / 7— )52-- __ • • I _ (Office Use Only) his ®fa meQO/c CITY OF IOWA CITY APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m.to 3 p.m., Monday—Friday) 410 East Washington Street Iowa City, Iowa 52240-I 826 Failure to complete the "required"information will result in denial of the application (319) 356-5040 (319) 356-5497 FAX First Midde Last 1. Name (REQUIRED) y ill rn b 4 ItA far a ArD L '//t/, J 2. Address (REQUIRED) L►(7fr Seo ? L 2 p�T�t� c � 3. Contact Information(REQUIRED) Email: ---� Cell Phone: '7c -2616 9169 (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) lo/ o 6_ ao 11/ b. Taxicab Business Name(REQUIRED) . r c, e 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? WO Type of offense Where When What happened to the charge?(Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other /\/' /3 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? 0-'('y Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? Iflease,es Y p =ptovide name(s) --171 -I tea' DEPARTMENT OF CRIMINAL INVESTIGATION (DCI)REPORT AND STA EIPPIFIEtf` DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLIGt:01711EFIREVIrt You must apply for an individual Department of Criminal Investigation Report(form aveiTable-upon 1 ►lest). (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 a valid Driver's license number 2.(7. -A ,j6-8 o5 issued on o .0 b,)'(expiring on NO, 06 f 1 . I understand that if I 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 `�' � Date ©l .-15,-[J *********************w*********************y, A*****AAAA nt*t,*i,a,yw-.*********************+»************n****.r+AAAA****,t**n*******i.****** STATE OF IOWA COUNTY OF JOHNSON ) II Subscri ed and sworn to before me by i4 csu rD i . PJOu fet R v"--- on this 19- day of Zo1 1 AENDY S.NAM Notary Public;y .nd for the State ,f Iowa **,.**.************infririnleillr**Air****,H**** *********************************************************************************:�*inirlrle*****-kir* 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 Cil Title 5, Chapter 2, City Code). Expira on d. •- o s river'. license , / ' Z r 1/1 )-117I Signature if 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/ 17 Si nature of City Clerlr designee , ate ***A****#*********************************AAAA********************* **********************AAAA******AAAA*AAAA**************AAAA******** Office Use Only Approved application y~'--+ DCI report — �-- State certified driving record 27i Website update .. Gerk/TAXIDRIVBADGEAPPL92014amended.DOC 07/2016 /AAA J Page 1 of 2 a • SMARTER I SIMPLER I CUSTOMER DRIVEN www.iowadot.gov Office of Driver Services PO Box 9204(Des Moines,IA 50306-9204 Phone:515-244-9124 1800-532-1121 i Fax:515-239-1837 www.iowadot: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: ,.....,, j�,'!1jy 9/15/2017 ir � f.�� °ems Office of Driver Services Iowa Department of Transportation ` -J Name: Nourain, Hamad Mohamed DL/ID: 212AN5805 (IA) -_{C) CO f" J I 0 http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 9/15/2017 Page 2 of 2 Cr,1 lb http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 9/15/2017 �. •r ,�• cv , rZ,IV• V.1 Clef vi VI Iminai lI,vCJII6ptIUII �U� UM) r, 1�1 OS,/07/2017 i6: ... :s2i•, r..+v2/002 • t '�U}1IA CL`b67:T>4frst(11t`�� Record Check �� rf�er�`CC���a _ - - • DCI Account Number; ia — "(i)'xppli:able) • 1'0: Iowa Gicisiult of Criminal Ltt'estf 2tio11 (tupirort Operationsl3urean, 1" ['loot 1't'rnn: Cit f jpv u C'ffi __ 2)5 , 7'"Street Citz'Caerk's Office E, — Des Moines,Tows 5031y 4/0E.`�Jashrn.(on Street (515)725-6066 (515)725-6080 Fax _ £ate,_1.4 5�;4� Phone: 319-356-5041 Parc: 319-356-54.97 —_— I am res nesting an Iowa Criminal History Record Check on: Last Name pnanclntc ) First Name O LL -,�•; (mandulur)) Middle Name (reeomglrodccl) Aft) .VLA'!•/J VJ \, iN\ cA j N o a 01 t — Date of Birth (mandator)") � �I �Gender(mandatory) Socia( Security Number (recommended) --�— 'tale OFelnale ��j Ca I O O 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 request. - -. I/ Pl' RPrEItSG':.1Lcleby.giv� ��at pissiOn-fDF-tile•&bOv nt ,(1sInvestigatiwt(DC1). My criminal history`tiara concerning me that is maintained by�thee DCI n be elcas d as allociuNcanduvrzerlorzt w d by law,i chtrrrh the Division of Criminal Gb'reiver Signature: °"------ ------------------------ ______________ ------ „...s •__. Y f Aci jsmzLcr — rnni aX isrT :Record Check Results „ (uCi use only) As of q•��,- � 1 - , - _, a search of the provided name and date of birth revealed;' c1'*t T'�l No Iowa Criminal History Record found with DCI c- ..': t l J . Iowa Criminal Bist oayl2ecord attached, DCl ur• 1)01 initials_C__ C DCI-77 (08/25/10) u ~— - _ Received Tioie Sep, 7. 2017 2 46PM No. 6380