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HomeMy WebLinkAbout14-220 r Authorization Number i 1 (Office Use Only) ^:..: dry .:III A® imeamlair 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 (319) 356-5040 (319) 356-5497 FAX First Middlest 1. Name (REQUIRED) Ali/ - c flit SG �" � -{CLNww �- � .e 2. Mailing Address (REQUIRED) 1 i'� �� ��Y 1-471 , ivp•,r f�'\ e-i `( / rt-1 3. Contact Information (REQUIRED) Email: 5144,107ria ,-.,c:N.L. tc nn Cell Phone: (J I 4. Prior experience in transportation of passengers: I talc „k. Cct,11 1A 1 1 )4,6--- 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /U 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? /'JC Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? XcS Type of offense Where When SP{ .A- J /3c / 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /L'C Type of offense Where When cD 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please proid thEfilame(s}t C c-)-< I ,— N f DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED rn DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIEW °""il You must apply for an individual Department of Criminal Investigation Report (form available upoequest). (OVER FOR REQUIRED SIGNATURE AND NOTARY) 09/2014 I I ereby certify that I have i�sued to me by the Iowa Department of Transportation a valid Chauffeur's license number Ativ,A.-c.t.,--A ( Ox mc- . 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 tim-s 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 Maar= Date I,C/2- I 2-c I CA- N! ' 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. STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by ‘ .,\r\r„,�,\ �10�a hnm XQ sc, , On this 4- `\ day of �i';,•••"1.-„,,,_ l - Notary blit in and for the State of Iowa )I 31L I 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). 1 ______AD/2—/LY Signa - . :.-i ief or designee Da 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. /J�r- <>/ k • ' Z ' / / /// Signa ure of City Clerk or designee ate Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width) and 51/2" (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update Clerk/TAXIDRIVBADGEAPPL92014amended.DOC 09/2014 Sep. 29. 2014 11 : 24AM Div of Criminal Investigation No. 0788 P. 4/7 Sep..22, 2014 1 :25PM City Clerk - City of Iowa City No. 521/ P. 2 �1t 61 P oor STATE OF IOWA V A ", 464f .! qv nvCitao�� History cod Check ".-:;0;; : law Request Form - .r" • DCX Account Number! 1-1QC)p2 -F' (if eapllcebte) To; Iowa Division of Criminal Investigation l4 om: City of Iowa City Support Operations Bureau, 1`t l?loot• City Clerk's Office • 215 E, 7`"Street 410 E.Washington Street Da Moines,Iowa 50319 (515)725-6066 Yowa City, IA 52240 (515)725-6080 Fast Phone; 319-356-504/ • • Fax 319-356-5497 I am reguosting an Iowa Criminal 1-listoly Reoord Check on: Last Name (mandatory) First Name(mandaloYth Middle Name(recommended) IAD v►nvv‘C{ Al4me.J NIv3Q Date of Birth (mandatory) Gender(mandatory) Social Security Number(recommended) /I l 1166 aa-ale Dremaie 577--53 -Li2- 66 Waiver frtformation: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. . • • Waiver Release;1 hereby give permission for the aboi reque ng official to condo et an Iowa criminaI history sword ohccic with the Division of Criminal Investigation(DCI). Any criminal history data concerning ntat is mat toed by the DCI may be released as allowed by law rf Waiver Signature; i/f Iowa Criminal History Record Check Results (DC1use oniy) As of C1 (1 a search of the provided name and date of birth revealed: No Iowa Criminal History Record found with DCI 0 Iowa Criminal flistory Record attached,DCI# • DCX initials • RP(.P. ivr' TImP. SPn. 77. 7014 1 : MM No. 075A • GIOWADOT SMARTER I SIMPLER I CUSTOMER DRIVEN wvvw iawado go Office of©river Services PO Box 9204!Des Moines,IA 50306-9204 Phone:515-244-9124 1800-532-1121 I Fax:515-239-1837 waw.iowadot.gov Certified Abstract of Driving Record Inquiry Date: 10/2/2014 DL/ID #: 519AG3626(IA) Customer#: 5827626 Name: Mohammed,Ahmed Class: D ID Status: None Musa Address: 1147 WINCHESTER LN Audit#: 8091888 DL Status: VAL Issue Date: 05/21/2014 CDL Status: Nqn City/State: NORTH LIBERTY, IA Expiration 09/11/2016 CDL Cert Noce 523179162 Date: Status: L:) O Endorsements: 3 CDL Med NoP� Status: .y Mailing Address: 1147 WINCHESTER LN Restrictions: NONE Restriction Nop l Date of Birth: 9/11/1966 SupplemeTWti� Mailing City/State: NORTH LIBERTY, IA Sex: M CC 523179162 ©""' History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 11/05/2011 11/30/2011 592 Speed Johnson 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: �4� `i1'4�� 10/2/2014 ;4: IOWA • a. °SI-D. O. Tie 4‘evy 4206,101/4exA • ��q�� '•••••'' Jr Office of Driver Services Iowa Department of Transportation Name: Mohammed, Ahmed Musa DL/ID: 519AG3626