HomeMy WebLinkAbout15-100o r
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
Name (REQUIRED)
IDENTIFICATION NO. / J — / 00
(Office Use Only)
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 result in denial of the application
First
2. Address (REQUIRED) 2� I V1 �C j{% rtya �IC)+/1 A� Cj q
3, Contact Information (REQUIRED) Email: w , r� r? Cdr ooLk � Y d ool -cy4 cell PhoneC`?I5) �( 71_ 67 yo
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) O 4 — �A'— 12e,22
b. Taxicab Business Name (REQUIRED) _ zv LUa V! j7a. ( LC !�
5. Prior experience in transportation of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Type of offense
Where
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please
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DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STAB CEFfjj7.T�F
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEFR?)EVIEW
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
IN
02/2015
l&I
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a va Chauffeur's license number
`�� [ % issued on i iexpiring on a d —2' . 1 understand that if I
fa sely 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 Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant 6-OY C�ld t 17,6 rr`Y Date. OG -1 2 _,2ol 5
STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn10 1 , before me by u 4 e�r Q`I �� g }?1 � on this
I1},L, day of
_.
VENDYS.MAYER I Notary Public
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 orwelfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license (—j'
j
Signa r of Police Chief or designee
ate
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
Signat of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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Clerk/rAXIDRIVBADGE PPL92014a..nded DOC 03/2015
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Clerk/rAXIDRIVBADGE PPL92014a..nded DOC 03/2015
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Certified Abstract of Driving Record
Inquiry Date:
5/13/2015
DL/ID ff;
379AE8597 (IA)
Customer lf:
5558422
Name:
Ahmed, Emad EI Dine
Class:
D
ID Status:
None
01/23/2013
Bairm
B64
No Insurance Card
Johnson
IA
Address:
342 FINKBINE LN APT 9 Audit 7F:
7899906
OL Status:
VAL
IA
Issue Date:
03/19/2014
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
O6/26/2022
CDL Cert
None
Occurrence JUR
522461714
Date:
08/12/2013
Status:
D53 Non -Payment of Iowa Fine
IA
IA
Endorsements:
3
COL Med
None
Status:
Mailing Address:
PO BOX 2044
Restrictions:
NONE
Restriction
None
Date of Birth:
6/26/1974
Supplement:
Mailing City/State:
IOWA CITY, IA
Sex:
M
522442044
History Information
Convictions
Citativn Date
Conviction
Date ACD
Explanation
County
JUR
01/09/2011
02/09/2011
S92
Speed
Johnson
IA
01/23/2013
04/23/2013
B64
No Insurance Card
Johnson
IA
12/15/2013
01/17/2014
B20
Driving While Suspended Denied, Cancelled,
Revoked Johnson
IA
Sanctions
.hype
Effective
End
ACD Explanation
Occurrence JUR
JUR
Suspended
08/12/2013
03/09/2014
D53 Non -Payment of Iowa Fine
IA
IA
Name: Ahmed, Emad EI Dine Bairm DL/ID: 379AE8597
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:
='t1ENIClf �4'a
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IOWA'�s
iv:- n it T :,F 5/13/2015
8pr.L0, LUI) II:VbAIVI
First Name onendam) Middle Name (recommended)
Ulv
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No 791U 1/1
0./27/2096 13:.0 Lode «+.,002/002
STATE OF ROWA
Criminal Hiaorry Record Check N
Request Form
To: Iowa Division of Criminal investigation
Support operations Bureau, I" Fl,".
215 L. 7"' Street
Des Moines, Iowa 50319
(515) 725-6066
(515) 725-6000 Fax
I am renue0h,& an Tnw� D ----A ni --1- --.
]SCI /account 1` uunber: L10' a "r
�(ifapplIcob re) -
Frons; City of Iowa L,ipy
City Cler)(16 office
410 E, Washington Street
1Dwe City, IA 52240
Phone; 319-356-5041
Fax: 3110 356-5497
Last Name (n,andaron')
First Name onendam) Middle Name (recommended)
4imed
Date of Dll'tL pnantlalrry9 Gender (,nwsdalery Social Security Number recommrndee)
0v -2d' 19%� � 2if-7 oy— �-77c)
LJMaIe ®Female
Waiver Informatiort: Without a signed waiver from th777� st, a complete criminal history record may nol
be releasable, per Code offowa, Chapter 692.2. For con ecord lnformation, as allowed by tan', always
obtain a waiver si nature from the snb ect of the re .est.
Raiver Release: I hereby kvc prmsrssion for Elie above re4acsuna offelal to roneuci en Iona criminal nislory record chedc Mlh rhe Division of Criminal
lovesiigalion(t)CI). Any criminal Uislory dale cwseerning me ihalis mainlainrd by Ise DC( may be released as allowed by lalV.
Waiver Signature: J e 1 j I o e , A
—
Yowa Criminal )Eiistor flteeo>rd Check Results
As of, -2 {6 �` a search of the provided nanne and date of birth
No Iowa Uiminal History Record found with DCX
Iowa Criminal History Record attached, DQ #
DCI irlitials__-
I)CI-77 (08/25/10)
Received Time Apr,2), 2015 1:34PM No.6397
(DCI me wily)
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