HomeMy WebLinkAbout19-010i f I r aiL
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(3 19) 356-5497 FAX
Last
1. Name (REQUIRED)
2. Address (REQUIRED,
3. Contact Information (REQUIRED) Email: Inn u v � SRM r• ,y (b qu v Cell Phone:
(AII written communication sent via email)
IDENTIFICATION NO. r I-/
(Office Use Onl
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
Failure to complete the "required" information will resuh in denial of the application
First Middle
4a. Driver's License expiration date (REQUIRED) _p q- 7 66- 2 o 2 n
b. Taxicab Business Name (REQUIRED)
S. Prior experience in transportation of pa
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? �vib
Tvce of offense Where When
ti
0
U
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? 4A2
Where
h S+yu
A
What happened to the charge? (Circle one)
Convicted Dismissed Deferred
When
Suspended Plead Guilty Other
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? /VC2
Tvce 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)
AND
04/2018
' APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
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).
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
16 2, A N �/ Z issued on o /- u 2 - % 9 expiring on o `/- 2 �- 20 . 1 understand that if I
falsely answer any questions in this application, that this application may 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 authorization to be a taxicab driver is granted, to comply at all
times with all of the provisions of TjtI& &,, Ci!�er 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicel .11 Date 6 /- 2Z - I I
STATE OF IOWA )
COUNTY OF JOHNSON ) p
Subscribed and swor h
to before me by Z:�aO %A 5 Aa�M i �� }-C��o on this ;z a- day of
WIENDY S. MAYER
ComIT1166 n NumbN 72W2�
Notary Publi n and for the Sta of Iowa
ffYk/iR1MYtYrtflffHrf(Rf1f4H41rtf:Flififff#*Ff4ffMHeffffM I(flffM'Rk1(fif44iRRlfftiftf!!Y!f#lfff'HR/eflf N�4f
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Driv 's s -e7
Signature lice Chief or designee
-Z� N
O
_ •G
01-2 Z
Date na
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN.IOWA CITY PDR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
�1 n n
designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
/--),--_�'-)C,
Date
aerkrrA%IDRN 6kDGFAPPL.9201BamaMeO.DOC 04/2018
qXI b rage 1 o2 t
C,JIDWADOT ,IL5V9l �E] QV
SMARTER I SIMPLER 1 CUSTOMER DRIVEN /W
Driver & Identification Services
IO Box 9204 I Des Moines 1A5030"204
More: 515.24&91241 FaC 515-239.1837'
Inquiry
Date:
Customer
tt:
Name:
Address:
1/9/2019
6558832
Certified Abstract of Driving Record
DL/ID #: 163AN4812 (IA) CDL Permit Class: None
Class; D
Shamseldin Mustafa, Audit #:
Murtada M
1926 Broadway Si Apt C Issue Date:
3509451
01/02/2019
- -
Expiration . 04/24/2020 ..
Expiration Date:
Date:
City/State:
Iowa City, IA 522407068 Endorsements: Chauffeur 3
Mailing
1926 Broadway St Apt C Restrictions: Corrective Lenses
Address;
Restriction None
Mailing
Iowa City, IA 522407068 Supplement:
City/State:
None
Date of
1/1/1973
Birth:
None
Sex:
M
History Information
Convictions
CDL Permit Issue None
Date;
CDL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
CD Permit
None.
Res rictions:
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit
ELG
Status:
CDL Cert Status:
None
CDL Med Status: None
0
Citation Date _Conviction Date ACD _ Explanation _ _ 1UR _unty
12/14/2017 01/24/2018 D70 IObstru�cted Vision irA hnso
-Accidents - Accident'involVement IndicatedAtiesir NOT'tnean the individual was at fault tvdF3 cltaran.
Accident Date 3UR Case Number
12/02/2016 '----._. IA -- ___.—. _
_.1955632--
C3
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Name: Shamseldin Mustafa, Murtada M DL/ID: 163AN4812 (IA)
Pursuant to Iowa Code §321.10, I, Darcy Doty, Driver & Identification Services, Iowa Department of Transportation, do hereby
certify that I am the custodian of the records held by Driver & Identification Services, that this is a true and accurate copy of an
cfficiai 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
t^is date:
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http://l72.29.254.55/drivers/reports/oustomerhistory/certifieddrivingrecord.aspx 1/9/2019
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Received Time Jan. 14. 2019 10:41AM No -9353
No. 0133 P. 2/2
DISCLAIMER
This response can only include public criminal history data. Under Iowa law, most
juvenile records are confidential. Confidential juvenile court records, if any, cannot be
included in this response. A signed release authorization is not sufficient to obtain this
information from the Division of Criminal Investigation. In order to request the release of
confidential juvenile records, if any, an application must be filed pursuant to Iowa Code
section 232.147(18).
Additionally, criminal history data concerning convictions for certain juvenile sex
offenses can be found on the Iowa Sex Offender Registry:
http.,Ilwww.iowasexoffender.com/. However, even though some information is available
on this site, the actual records for juveniles may still be confidential and any confidential
juvenile records cannot be provided with this record. In order to request the release of
confidentiai juvenile records, if any, an application must be filed pursuant to Iowa Code
section 232.147(18).
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Driver &'Identification Services
Iowa Department of Transportation
Name: Shamseldin Mustafa, Murtada M DL/ID: 163AN4812 (IA)
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http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.asp)i 1/9/2019