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Home My WebLink About14-270 Authorization Number /9-- �C? 76-7 — 1 (Office Use Only) MIL 1114214 APPLICATION FOR TAXI/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 (3I9) 356-504 (319) 356-5497 FAX First Middle Last 1. Name(REQUIRED) 5A1"'1Z' A504_11-4 AW/ WS, 2. Mailing Address (REQUIRED) lb 9— 2-14* lavt. C..z)(41s51\4 'A C2-1-41 3. Contact Information (REQUIRED) Email: 547v1/40,5,'-\`\‘\"\ -- c-cs'A'` Cell Phone: (3\5) 3' �S Z 4. Prior experience in transportation of passengers: S-1-ats tet' \eiCWj tit-AAP--- `` Lo 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? V 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? 140 Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? Type of offense9 Where When •v�.,,,r �� w hnk pw�e% CRI 11- I S. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? No 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) PI O DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW You must apply for an individual Department of Criminal Investigation Report(form available upon request). (OVER FOR REQUIRED SIGNATURE AND NOTARY) 09/2014 • I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 7z%/ce �" s J . 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 time _II of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) 00 Signature of Applicant _ 0 Date DccQ.Kje_r- 2�I 7-00A YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. ****************************************AAAA A k*********************************** ****************************************#************* STATE OF IOWA COUNTY OF JOHNSON ) scribed and sworn to before me by a, Ih I G . III/4 S . On this 7" day of , / • 7/ 2.-.5...„4...„) Notary blic in and for the State of Iowa ************************************************************************************************************************************************ 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). /2 ,z //9 Signat e of Po' Chief or designee Date YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org. Signatu of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width)and 5 1/2" (height) and prominently displayed to all passengers. ***************#******************************************************************************************************************************** Office Use Only Approved application DCI report State certified driving record Website update Clerk/TAXIDRNBADGEAPPL92014amended.DOC 09/2014 Dec, 23. 2014 12: 55PM1 Div of Criminal Investigation No. 6835 P. 1/1 ■ 'v��, i i, LV I T I I J n v+ l l n VI ‘ r v i i v TIa v t l y Iry• J'1 1 U I . L ii ■ • fv, nF1't j�`, STATE.ILS/ OF IOWA L71 f.:(,--i...-/-'2.10=1-.-1.-':::'.)::':'... r,.0AA4` �/`��C, A0.4. 1111,1 �i C1tniI9 inaI tory .Record C . l.„. ! ' ;r. Reques Form „; 01'I. ti te %fir; t ACI Account Number: U O�— F • (i(applicable) To: Iowa Division of Criminal Investigation From; City of Iowa City Support Operations Bureau,1"Floor City Clerk's Office 215 F.9th Street 410 E.Washington Street Des Moines,Iowa 50319 (515)925-6066 Iowa City, IA 52240 (515)125-6080 Fax . Phone! 319-356-5041 .9 le,' - Fax; 319-356.5497 I am requesting an Iowa Criminal History Record Check on: . Last NAM) (urandatory) First Name (mandatory) Middle Name(recommended) P1 O.S r6\ SA MT A Date of Birth(niandatorl� Gender(mandatory) Social Security Number'recommended) t I of \ t°1 —ck Dale °Female 636 '-c —9s o Waiver Information: Without a signed waiver from the subject of the request,a complete criminal history record may not be releasable,por 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. Valuer Release,l hereby give permission for the Above re.uesting,ficial to conduct an Towa criminal history record check with tho Division of Criminal Investigation(DCI), Any cimiuel history data concerning me that I it; •by the DCI maybe released as allowed by law- • Waiver Sl'gnuture: -. . ...i /. Iowa C 'minas Histor Record Check ' es I ' (Daus*only) As of by 4/4--i ,a search of the provided name and date of birth revealed: NI No Iowa Criminal 1-lis tory Record found with DCI , 0 Iowa Criminal History Record attached,DCI# . t.) . . DCI initials_ Received Tirrie7•0ec„,12;la014 1 : 13PM No. 6690 . F • Page 1 of 2 OINA EiciT SMARTER I SIMPLER I CUSTOMER DRIVEN WWW'IOWaCIOt.gOV Office of Driver Services PO Box 9204 I 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 Date: 12/20/2014 DL/ID #: 470AF6089 (IA) Customer#: 3493227 Name: Musa,Sami Class: D ID Status: None Abdallaawad Address: 1017 20TH AVE Audit#: 8703337 DL Status: VAL Issue Date: 12/18/2014 CDL Status: None City/State: CORALVILLE, IA Expiration 01/01/2023 CDL Cert None 522411342 Date: Status: Endorsements: 3 CDL Med None Status: Mailing Address: 1017 20TH AVE Restrictions: Corrective Lenses Restriction None Date of Birth: 1/1/1979 Supplement: Mailing City/State: CORALVILLE, IA Sex: M 522411342 History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 06/23/2012 09/27/2012 E01 ;Operating Without Equipment OH Name: Musa, Sami Abdallaawad DL/ID:470AF6089 Pursuant to Iowa Code §321.10, I, Klm 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: 1prvC 07RR4,, 12/20/2014 4' IOWA '410 ae: icy e cm' D. O.T. y'%,,Of At%% Officeof Driver Department Services Iowa Transportation Name: Musa, Sami Abdallaawad DL/ID:470AF6089 12/20/2014