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Home My WebLink About14-213 Authorization Number / —2 JI — i (Office Use Only) �► III imgatudialir 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) 6- 040 (319) FAX First Middle Last 1. Name (REQUIRED) \� na (s'2-1^60., ► 2. Mailing Address (REQUIRED) 36 Av,i5Ao^ S '3, -' c,aY f A 522_44 3. Contact Information (REQUIRED) Email: V z .- 6,2 Lo Cell Phone: 3('47( 7 3 r 1 4. Prior experience in transportation of/passengers: I 1 C�Yovc� ,a�o1 �' c` /6..v- 4.4 / k llk-irn (^A Gt 2 vc-- c+?t ti-•\ � •-� c; & y be.la— N V‘.-C)..� 2Ch'g 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? IV Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? y Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? IV Type of offense Where When r.,� 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the r te(s) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CbTliFlpikrr. DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHFEFZREV 3 ' rri 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 sued to me by the Iowa Department of Transportation a valid Chauffeur's license number L.jr.t.t A e— 2 k°6 . 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 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 CA / I61 ( 1(4 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 tG .i 1 f 4 A .44. Scl-e-e cQ . On this ) 4 -L1.1._ day of sailtou_kla•._ 4 WENDY S.MAYER 1. 5 - t'�1��. CC..,.niealnn Number 729428 Notary Public i and for the State f Iowa M Commiss o Expires _,ow 1 -I �,-/C2 ************************************************************************************************************************************************ 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 welfar- . . id- • .f the City of Iowa City(i itie 5,Chapter 2, City Code). - re if 'oli e 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. A.. K - 9 / -/ of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 81/2" (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/TAXIDRNBADGEAPPL92014amended.DOC 09/2014 Sep. 15. 2014 10: 04AM Div of Criminal Investigation No. 0220 P. 2/2 •- Se.P111. 2014 2: 20PM City Clerk - City of Iowa City No. 5i P. 1 • VIFru r STATE OF IOWA �% :-�:'n-=t:' s r 5 (�rca»zrnn�aa� llg ®Ifs Record cC�ecl4� 'res• .z kali) Ike uest Flomr `..;\� `'may 1 sir, r�',Ir DC1 Account Number: U Cb -rte (if app'cable) To: towwa Division of Criminal Investigation From: City of Iowa City Support Operations Bureau, 1't Floor City Clerk's Office 21S E,1'h Street 410 E.Washington Street Des Moines,Iowa S0319 (51S)726-6066 Iowa City, TA 52240' (51g)925.60S0 Fax Phone; 319-3564O4i . Fax: 319-356-6491 6qe&'ZO • I am requesting an Iowa Criminal Histoly,Record Check on: Last NaT ntatldaloty) . First Name(mandatory) Mcddle Name(recommended) ee-C9 PAck Cc a Az.,,,,a.v.1,- iv\ . Date of Birth(mandatory) Gender(mandatory) Social Securi Number recommended a ( V1 I teig 3Male InFemale 2.z-8- 95-- ttc I3 S ' Waiver Inforrnmtioisa Without a signed waiver from the subject of the request,a complete criminal history record may not be releasable, per Code()flown,Chapter 692,2,For complete criminal history record Information,as allowed by law,always obtain a waiver signature from the sUb,lect of the request. . Waive,-.Release,I hereby give permission for the above requesting official to conduct an Iowa crintinal history record check with the Division of Criminal Investigation(DCI)- Any edmInal history data concerning me that Is maintained by the DCI may be released as allowed by low. ' Waiver Sigrruture: _. —! • • Iowa Criminal History Record Check i',.e,sults a „;(ooF saa„ty)- y-- ' /5—/�/ (2� -0. . .� As of • , a search of the provided name and date of birth revealed: c.,-.< . — - No Iowa.Criminal History Record found with DCI = 6 I 0 Iowa.Criminal History Record attached,DCI# , DCI initials.. 0 o- -- ..., ! T :..,,.—C .. 11 —')111 5— 0. 1QPM—Me AA - - - .C111120*1IUUA DOT `�....„ www.iowadot.gov SMARTER I SIMPLER I CUSTOMER DRIVEN..........,---------... Office of Driver Services PO Box 9204 .Des Moines.IA 50306-9204 Phone:515-244-9124 1 800-532-1121 1 Fax:515-239-1837 www.iowadot.gov Certified Abstract of Driving Record Inquiry Date: 9/19/2014 DL/ID#: 144AC2108(IA) Customer#: 5262644 Name: Saeed, Khalid Azhari Class: D ID Status: None Mohamed Address: 36 ANISTON ST Audit#: 6182099 DL Status: VAL Issue Date: 08/03/2012 CDL Status: None City/State: IOWA CITY,IA Expiration 08/17/2017 CDL Cert None 522402216 Date: Status: Endorsements: 3 CDL Med Status: None Mailing Address: 36 ANISTON ST Restrictions: NONE Restriction None Date of Birth: 8/17/1983 Supplement: Mailing City/State: IOWA CITY, IA Sex: M 522402216 History Information Convictions Citation Date Conviction Date ACD Explanation County 3UR 10/01/2010 10/25/2010 592 Speed Lee IA 08/26/2011 09/19/2011 S93 Speed Johnson IA 02/09/2012 08/10/2012 F02 No Child Restraint Johnson IA 02/09/2012 08/10/2012 E50 Defective Equipment Johnson IA Name: Saeed, Khalid Azhari Mohamed DL/ID: 144AC2108 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: N E Ifk �=`SO''..''''-.N�o�l, 9/19/2014 -y-,-f..) r 1?1 IOWA ..M '' -�v °9„ .* e �'4,1)::••. 4, "+ ko sem• h, 4p DRIVER$ Office of Driver Services �-<F" Iowa Department of Transportation..,_.i'•? '13 177 ...�e; max. Name:Saeed, Khalid Azhari Mohamed DL/ID: 144AC2108 q