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CITY OF IOWA CITY
410 East Washington Street
iw Cil Iowa 52240-1826
319 356-5040 C ^ L L ��4rSd4y
(319) 356-5497 FAX
1. Name
Authorization Number /.)- ^ /'8v
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m, to 3 p.m., Monday - Friday.)
(Office Use Only)
2. Mailing Address '{�:2,A , Tot>xx CAI , ZA SZ2�
3. Telephone: Home 71- (St'l Other:
4. Prior experience in transportation of passengers: d✓tt yCalr
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? A -)n
Type of offense Where When
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?A )a
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? C S
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? A -AO
Type of offense
Where
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
/) n
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW
/ILSzl/
You must apply for an individual Department of Criminal Investigation Report (form available upon request) The re-
port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli-
cation.
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
aendtmWvbaa9 06/2012
FA
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license numtle(
19A(t V� 2 . I understand that if I falsely answer any questions in this application, that this
application may be denied. I understand that if I falsely answer any of the questions in this application, that this application will
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 a license
is granted, to comply at all times witall of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public) l /
Sigr
Date 22A 2 jo 12
STATE OF IOWA )
COUNTY OF JOHNSON ) II - ^�^
bscribed and sworn to before me by I� VIMe 9� 1 ' DVlQ Yt L ✓Lle On this 1 l " ` day of
I Z
r+'k KELLIE K. TUTTLE Notary Public in and for the State of Iowa
e i Caunuia ieu Ilam§xr
�� My Ca�nrr)Ssioh rE)cpires
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the issuance would be detrimental to the safety, health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
e or designee Ignee Date
or designee Date
NOT VALID UNTIL Police Chief and City Clerk have approved and authorized taxi driver names placed on the city website at
icgov.org.
Taxi cab businesses are required to provide Driver Identification cards.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
ciarknaiiddwadgeswoio. 06/2012
V Arue� 24�
r'
2012 4:27PM Div of Criminal Investigation
tu12 4:IOrltl' blty ulerx - r.Ity o1 i o w a t,ity
Requegt Form
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To; Iowa Division Of Cdralhai Investigation
Support Operatloha Eurealr,1"Floor
215 R 7'r',Rroet
Des Moines) Iowa 50319
(515) 725.6066
(515) 725-6080 )Fax
Record Check on:
Mt'stName (man
No, 2074 P. 1/6
No. my r. 1
DCI Account 14tunber: ,V -o0.9 �F—
(If Qpplimble)
Z-om: CITY OF IOWA, CITY
CITY! MRX119 ORRICE
410 E. YW✓ASHIMOTON 5Tl1tMi
IOWA CITY XO'WA 62,240
Phone: 319-356-5041
Fax; 31935616497
I
NtoofBirth (bamdatoly) IGender (Aamds[ory) I8oeial5ecurlitvNumbor(recommended) I
Ib9/I( //I b6 I ale M?oxua e
IWaiver Information., Without R signedwaivek, fk oin the subject of the request, acompleteeriminoIJilstoryrocaildniayiiot I
berelensable, per Code ofIoWa,Chapter 692,2.For co, nnNetecriminalhirtoryrecordinformatlon,asallowed6ylaW,alWays
ob taf It a waiver silrnatore From the subieet of the request.
WrffbeP.RelenBe; Iherobygive pemilsllmr
xneesllganon(M). Any mrofnal hirlary data co
condom an toWa ctBn(nal briery record checkwfdr Vic Dlylston ofOdminat
,e DCtntay be refeascd m allowed bylaw.
Iowa Criminal History Record Check Regultg
As of a search of the provided name and date of birth revealed:
No Iowa Criminal HistoxyRecord found with DCI
Iowt. Cximinal.11istoxyRecord attached, DCI#
DCT
Received Time Auz. 17.."2012 4:18PM No. 169
(OCt use only)
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Iowa Department of Transportation
Office Df driver Services (Toll Free) 8013-532-1121
PO Box 9204, Des Mmes, IA 50306-9204 515-244-9124
FAX: 515-239-1837
1*0
Inquiry Date: 8/28/2012
Name: Mohammed, Ahmed Musa
Address: 2425 BARTELT RD APT 2A
City/State: IOWA CITY, IA 522462709
Mailing Address: 2425 BARTELT RD APT 2A
Mailing City/State: IOWA CITY, IA 522462709
Convictions
Certified Abstract of Driving Record
DL/ID #: 519AG3626 (IA)
Class: D
Audit #: 5729811
Issue Date: 01/06/2012
Expiration Date: 09/11/2016
Endorsements: 3
Restrictions: NONE
Date of Birth: 9/11/1966
Sex: M
History Information
Customer #:
5827626
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Citation Date Conviction Date ACD Explanation County JUR
11/05/2011 11/30/2011 592 Speed 52 IA
Name: Mohammed, Ahmed Musa DL/ID: 519AG3626
Pursuant to Iowa Code §321.10, I, Kim Snook, 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:
"""•��9'4
8/28/2012
IOWA4°'
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Office Driver Services
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Iowa Department of Transportation
Name: Mohammed, Ahmed Musa DL/ID: 519AG3626