HomeMy WebLinkAbout14-037 Pa Authorization Number I r
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APPLICATION FOR TAXI 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
(319) 356-5040
(319) 356-5497 FAX
FirstMiddle La t
1. Name / Q�C1` I //41 a5A
2. Mailing Address 8(,-/ 7 j q71 nyl S f _LO(,Jo t y Z/-1 S Z 2 (o
3. Telephone: Home.--2)/9'- C72, i f?6 -3 Other:
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? t/i
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? //C
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? / /C
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? ye 5
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)
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)
GerWtaxidrivbadg 03/2013
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
i mai )7 . I understand that if I falsely answer any questions in this application, that this-
application
hinapplication 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 AliLair- Date - 2- S- I V'
STATE OF IOWA
COUNTY OF JOHNSON )
bscribed and sworn to before me by -} L}ro ZC , K. this��h-��✓L day of
_AS •
,�a'r a WENDY S.MAYS
o Notary Public in ar for the State of low_
a i Commission Number 729428
My CgrfrItssion Expires
*******# .********46,t*,*a, :1. .�1....v*****************************************************************************************************
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).
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Signature of Police 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.
Signature of City Clerk or designee /Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 '/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
derkAaxidrivbadgeapp2010.doc 03/2013
Y Feb. 20. 2014 9: 53AMA Div of Criminal Investigationy No. 3427 P. 1/15
e:,/4; STATE OF IOWAM-CV/•,t
4tis
7.7.1" &rriimi)Nall ]EUisttoir�'R' con-d Cheek t. ^„`�^
N' untVol ,> ,
r-N451)5 ! Request Form 'A. -.
DCI Account Number; ynD F
(if appl icablo)
To, Icwa Division of Criminal Investigation Promi City of ton City
Support Operations bureau,I"Vloor City Clerk's Office
215 E.7th Street 410 E.Washington 9ireet
Des 1VIoines,Iowa 50319
(515)725-6066 Iowa Gtigg, M 52240
(515)725-6000 Bax
rholnei 319-356-5041. •
• Faxt 319-356-5497
•
•
T mn requesting an Iowa Criminal Bistoty Iteoord Check on:
Last Name(mandatory) First Name(mandatory) 1Vfiddle Name
(reconmsended)
•
//
Date of Birth(mandatory) Gender(mandeloq) Social SecurityNumber(recommended!
•
029 - (� s • ado UFemale 051- 76 - Sg O 2-
Waiver IriJ'ormafion:Without a signed waiver from tjle subject of the request,a complete criminal history record may not
be releasable,per Code drown;Chapter 692.2.For complete criminal history record information,as allowed by Jaw,always
obtain a waiver signature from the subject of the request.
Waiver Release:lhetcby givo permission fez the above rupee 11118 official to conduct an Iowa u(nlnat history record check wits theInvlston ofCarninel
rnvestigation(pC1), Myulmindlhisiory dole concerning n Ihailrmalntaleedbyihoceleascdese0owodbylam
Waiver Signature: toe --
„se
• �II�[o�wli Citainal]HCi�tEory c_g a
r c�sgeSTI ff (ocluseonly) .
As of U rLV L. `1 , a search of the provided name and date of birth revealed: _
1/11 No Iowa Criminal History Record found with DCIrn
iYi•-.7-71
0 Iowa Criminal History Record attached,DCI# ; _ ••
ate- r z
DCI initials ": N
Received Time Feb. O. 2014 8: 19AM No. 3 1
4
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SMARTER I SIMPLER I CUSTOMER DRIVEN VItW1N'I(3wadot.gov
Office of Driver Services
PO Box 9204!Des Moines,IA 50306-9204
Phone:515-244-9124 I 800-532-1121 (Fax:515-239-1837
www.iowadot.gov
Certified Abstract of Driving Record
Inquiry Date: 2/25/2014 DL/ID It: 152DD8517(IA) Customer#: 4550505
Name: Musa, Mutwakil Mohmed Class: D ID Status: None
Address: 86 ANISTON ST Audit#: 5550672 DL Status: SUR
Issue Date: 10/05/2011 CDL Status: None
City/State: IOWA CITY,IA 522402216 Expiration 01/29/2017 CDL Cert Status: None
Date:
Endorsements: 3 CDL Med Status: None
Mailing Address: 86 ANISTON ST Restrictions: Corrective Lenses Restriction None
Date of Birth: 1/29/1965 Supplement:
Mailing City/State: IOWA CITY,IA 522402216 Sex: M
History Information
Accidents-Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
09/28/2011 649802 IA
Sanctions
Type Effective End ACD Explanation Occurrence JUR JUR
Suspended 08/02/2012 ._06/18/2013 D51 Non-Payment of Child Support IA IA
Suspended 08/25/2012 06/18/2013 D51 Non-Payment of Child Support IA IA
Name: Musa, Mutwakil Mohmed DL/ID: 152DD8517
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:
gc :3
42/25/2014
c a ectsock,Of'; 4� Office of Driver Services
41‘h,=:.--1:— Iowa Department of Transportation
Name: Musa, Mutwakil Mohmed DL/ID: 152DD8517