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HomeMy WebLinkAbout14-208 Authorization Number 14 -tIo? k 1 (Office Use Only) 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 Middle, Last / 1. Name (REQUIRED) 05 AU ii • i a ha Me 2. Mailing Address(REQUIRED) g Crtt2`5 Gr) CVc' Lc,A c C; !f j.A E,2 C 3. Contact Information (REQUIRED) Email: 05 /Yfe n c► Iia I P/01M61 I{(o`Cell Phone: 3 i (,141) .5 /(3,2. 4. Prior experience in transportation of passengers: 'I k16+✓P hr°e e (,4 y l V'vi 111 Iowa c;1- y 4 y 17 rie ye A-r 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When v (- 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? Type of Offense Where When /02 7. Have you been convicted of any traffic offenses in the last five years? 6t Type of offense Where When M`? la � o ObCcf -1-ra ,F;G S:eja / 5i5nu l )01)) 19,01- 8. 0l)) 12038. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Type of offense Where When N J C? r `w v 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prdWd the-nname( NO ri DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CIFP . DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVJVW 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 51( A(.� *S q ( . 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 V, i�//it 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 ) u scribed and sworn to before me by S • (Y-10 2---4-6\--10 r-R ' . On this 1day of pie.Iu-Car i ,�1 KE1 TU SLE 819 �L. (/ ! I o � Con '�� •m15"o�E pc esNt tary Public 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 = ' . mation which would indicate that the issuance would be detrimental to the safety, health or welfare of res'--nts oft - ' of Iowa City(Title 5,Chapter 2, City Code). Signature . 'olic'i"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 f City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8'/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 ClerkJTAXIDRNBADGEAPPL92014amended.DOC 09/2014 SMARTER I SIMPLER I CUSTOMER DRIVEN Office of Driver Services PO Box 9204 I Des Moines,fA 50306-9204 Phone:515-244-9124 i 800-632-1121 r Fax:515-239-1837 www.iowadot.gov Certified Abstract of Driving Record Inquiry Date: 9/10/2014 DL/ID#: 548AG4897 (IA) Customer#: 5870812 Name: Mohamed, Osman Rahmtalla Class: D ID Status: None GSM Elssid Address: 807 HUGHES ST Audit#: 6551793 DL Status: VAL Issue Date: 12/18/2012 CDL Status: None City/State: CORALVILLE, IA 522412143 Expiration Date: 12/13/2017 CDL Cert Status: None Endorsements: 3 CDL Med Status: None Mailing Address: 807 HUGHES ST Restrictions: NONE Restriction None Date of Birth: 12/13/1982 Supplement: Mailing City/State: CORALVILLE, IA 522412143 Sex: M History Information Convictions Citation Date Conviction Date ACD Explanation County JUR ................................. 10/03/2013 10/11/2013 M14 Fail to Obey Traffic Sign/Signal Johnson IA Accidents-Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number 3UR 10/03/2013 761029 IA Name: Mohamed, Osman Rahmtalla GSM Elssid DL/ID: 548AG4897 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 'sxMAN v O apt F ..'s% 9/10/2014 C''� ..c-- IA: -- 4: Iowa' ;• ,� , �i %%. D. ©.T. t .p ,4- _ �.,. ,I++11 4r DRIVER Office of Driver Services .,,<f--- Iowa Department of Transportation" r n - ..5 N .....67 Ca Name: Mohamed, Osman Rahmtalla GSM Elssid DL/ID: 548AG4897 c,^, .Sep, 10. 2014 6: 32PM Div of Criminal Investigation No. 9366 P. 6/8 cep. Lui.+ II : )onm Lity cittK - t, ity of LOWd kilt), Mi. JIIF P. t • • • • iOFpUB ♦ .7'r'', . ri STATE OF IOWA, \I �, a�' m ,`�� : Ciril r(ingi History Recoyd ChpaK `r �� ;y. I r .• \/ c ,, -+,a Request Foxrria -tx-.. . 4:- \0111, DCI Account Number:_ trktils. ___ (itepp)Ioabte) - To: Iowa Division of Criminal Investigation prom: City of Iowa City • Support Operations Bureau,1"Vidor City'Cleric's Offiee 2151;.1 h Street 410 F.Washiuge4 eetcn Des Moines,Iowa 50319 r - • (515)725-6066 • - Iowa City, IA STUCK. Fm— . (SS15)125-6090 Past —i Phone: 319-356,5041 -CI -0 . Fag: 319-M6-5`07 ;:..5 71 r'� moo; tm r, I am requesting an Iowa Criminal History Record Check on, Last Name(mandatory) First Name(u,andarory) Middle Name(ieconlmondoil) //WO ajr(g 0s7,74n R _ . Date of Birth(mandatory) Gender(mandatory) Social Security Numb or(recommenced) • 42 ,13- /9:g',2 �lVlale ❑Female 2 7 •Se 3 .- 9693 Waiver information:Without a signed waiver frcini the subject of the request,a complete criminal history record may not he releasable,per Code of Iowa,Chapter 692.2.For complete criminal history record information,a5 allowed by law,always obtain a waiver signature from the subject of the request. . - 'Waivelr Release:I bcrcby givo permission ibr the above requesting officio(lo conduct en lova ethnic el history record oh sok with tho DIvis ton or Criminal Investigation(DCI). Any criminal history data oouccming inc that is maintained by the DCI may be released as allowed by taw, • Waiver Signature: . • . _ ___IkkatA"."--- Iowa CriminalZeck Results (�CIuso:a»iy) As of q-10--I c...:, , a se�ercht o£tlie provided name and date of birth revealed; ��' ANo Iowa Criminal History Record found with DCI • �, 0 Iowa Criminal Ristory Record attached, Da# . DCT initials 1 J n . _ . . .. . I T:__ 0. __1'9/,1A 11 .CAAAfKI_ OC11