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HomeMy WebLinkAbout14-186 Authorization Number ) 4 - 1840 1 (Office Use Only) aza •Nt —imis son WI APPLICATION FOR TAXI/MOTORIZED PEDICAB VEHICLE DRIVER CITY OF IOWA CITY (Police Department review must be made 410 East Washington Street between 8 a.m.to 3 p.m., Monday–Friday.) Iowa City, Iowa 52240-1826 C___(3 I 9) 356-5040 (319) 356-5497 FAX First nR c��la�ne-G9 MiddleV\ 11\000(\Q. _ 1. Name c 2. Mailing Address ��\c r v \ > -- 2 1 OW G C.�'t,, ��c 22cL( i 3. Telephone: Home ` \e11 g3 9 6 2-2-- Other: 0 4. Prior experience in transportation of passengers: 3 Y-ecrS U yl fi n\ SC_\'\Gp\ 'r etc 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When 710 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 /Vo 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When ( w ° 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Type of offense Where When 4/0 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) /YO 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) clerWtaxidrivbadg 03/2014 I hereby c rtify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 6'O 1 V_ 2Q-1 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 wI 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 el _ Date 087/Z6/./ ./ ,- 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 ' ' 1r ko. ( , a\,.a►u=:A this day of A,-.1 i SSA- 1 s WENDY S.MAYER Notary Public in d for the State o wa e • S l.amr'n 'un Nurnbc,723420 4i M Commission Expires tow l ************************* ********************************************************************************************************************** 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)...ik — (15/26//Y. Signatur % '.e Chief or designee Date YOU AR- 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. Ai--1.-cer-2-L-1' k - /N,ai:L----- // Z Signature of City Clerk or designee ate Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width) and 5'/2" (height) and prominently displayed to all passengers. **************************************,.,..**************************************************************************************************** Office Use Only Approved application DCI report State certified driving record Website update clerk'taxidrivbadgeapp2o14.doc 03/2014 www iowadot goy SMARTER I SIMPLER I CUSTOMER DRIVE}.-_ .e - -- ofrcebf :-_ .-Services PO Box 9204[Des Moines,to 50306-9204 Phone:515-244-9124180D-532-11211 Fax:515-239-1837 wwwiawadot.gov Certified Abstract of Driving Record Inquiry Date: 8/23/2014 DL/ID#: 801AK7238 (IA) Customer#: 6212115 Name: Mohamed, Mohamed Osman Class: C ID Status: None Mukhtar Address: 2610 BARTELT RD APT 28 Audit#: 8309684 DL Status: VAL Issue Date: 07/31/2014 CDL Status: VAL City/State: IOWA CITY,IA 522462731 Expiration Date: 05/27/2022 CDL Cert Status: Non-Excepted Intrastate Endorsements: NONE CDL Med Status: None Mailing Address: 2610 BARTELT RD APT 28 Restrictions: Commercial Instruction Restriction CDL Instruction Permit Permit,Corrective Lenses, Supplement: Expires 1/31/2015 CDL Intrastate Only Date of Birth: 5/27/1961 Mailing City/State: IOWA CITY, IA 522462731 Sex: M History Information CLEAR DRIVING RECORD Name: Mohamed, Mohamed Osman Mukhtar DL/ID: 801AK7238 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: —'citllClf p''p ,`pQ. f4,"i, 8/23/2014 ,t•• IOWA '-#1 } ":3; D. O.T•;$, S 4Office of Driver Services a<<„Ox..w Iowa Department of Transportation Name: Mohamed, Mohamed Osman Mukhtar DL/ID: 801AK7238 LAeg. 22. 2014112:39PM en! of Criminal Investigation N., ' P.PP. 1/1 Aar,- STATE OF IIOWA - `ln.�/ ,, Criminal History Record Check . et. =``'a, Rials s ;,%° i 't l utiti 4 Request Form 4 , �'J e o% 44," DC1AccountNumber: 40D 1), (ifeppiieable) To: Iowa Division of Criminal Investigation Prom: City of Iowa City support Operations Bureau,1"Floor City Cleric's Office 215 E.7"'Street 410 E.Washington Street Des Moines,`(owa 50319 (515)725-6066 Iowa City, IA 52240 (515)725-6080 Fax . Phone: 319-356-5041 - - Fax 319-356-5497 Iain requesting an Iowa Criminal History Record Check on: Last Name (mandatory) -First Name(mandatory) IVIiddle Name(rewlnmraded) V\CVCO\e-C\N M6ha lme—CA ©-. - WAN ti\v\\CC\irreYvv Date of Birth(mandatory) Gendder'((maedatoty) Social Security Number(reccoonunanddeed) ' (D \ 9.--AA \Ok 6 \ Et ale ®Female (S 8 @.9 — 5,b 1-6 • Waiver Information:Without a signed waiver from the subject ofthe request,a complete criminal history record may not be releasable,per Code of Iowa, Chapter 692.2. gor comuiete crlininalhistory record lnformationyas allowed by law,always obtain a waiver signature from the subject of the request • Waiver Release:therebyglvopermissionforthoabovarcqueatingoalcieltoconductanIowacriminalhistoryrecordeireckwiththe ivisionofCriminal Investigation 0:0). My criminal history data conotatingmo ih s maintained by rho DC!may be released as allowed by law. Waiver Signature; I Iowa Crimidnal Xietory RecorChkecResults (Dot use Only) . • n As of g " Die)-'I ,, a search of the provided name and date of birth revealed: gNo Iowa Criminal History Record found with DCI 0 Iowa Criminal History Record attached,DCI# DCI initials Cie- n 1 T. is 'In'Irnnr / In nlnl 11 1,AA