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Home My WebLink About15-114VIII CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319)356-5497 FAX 1 2, 3. IDENTIFICATION NO. (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDIC (Police Department review must be made between 8 a.m. First x Name (REQUIRED) �r,,�"o Address (REQUIRED) Z Contact Information (REQUIRED) Email: 4a. Chauffeur's License expiration date (REQUIRED) It. Taxicab Business Name (REQUIRED) V: I1/ •v M Q ti&+EHLE DER � LeL on Friday) Cr-,)� w ;7fi al of the &mMication Pa � Las )�,r ritGl 11, (cm Cell Phone.JN 141/- 6Z6 I �n communication sent via email) 5. Prior experience in transportation of passengers: G �r/,i 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When 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? Type of offense Where When I ` e .1l What happened to the charge? (Circle one) 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 ofoffense Where When 9. Have you ever applied to be an Iowa City taxi drives 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). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that f Jave issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 21e (11 � 11 1 ,Q issued on t,'ll lbei4 expiring on e A/, / 7o,Z� I understand that if I falser lynam saver any questions in this application, that this application may be denied. 1grey e 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 grantdii�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;ga Notary Public) Signature of Applicant ��"'i"t� ��rrly Date 0 <�63�iS D� x s � N STATE OF IOWA )' COUNTYOFJOHNSON ) Subsribed and sworn to before me by N o" f GO 0__ �rl lP� on this � day of t 2-01 �,«we�_Turne� i��C.�r2 K ,,. ; „r;,nPr?,1E Notary Public in and for the State of Iowa *kk*k*****k*kk*k********YY**********k******£*******k**£*****kk*k*kkk**k*µµµk£**#kh*****#k****hh#k*kk**k#***k**Y******kk********#*kk************* 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). ExpirationAate of Chauffeur's license /l y`y/boa Sin ure & Poh a ief or designee Date 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. Sigg a lure of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update lO0 , Date aerwrnxmRivenocE PPL92014ari,erided.o00 03/2015 C4J10WAD0T wvAvJovvadetqov SMARTER I SIMPLER I CUSTOMEP ,tMIN Office of Driver Services PO Box 9204. s. Des Moines. lA 541306-9204 Phare: 51S_244 -,9124I800-532-1121} Fax 511-239-1837 wNN.iawadly.gc,V Certified Abstract of Driving Record Inquiry Date: 6/2/2015 DL/ID #: 239CC6458 (IA) Customer #: 1640461 Name: Omer, Najwa EI Awed Class: D ID Status: None Address: 322 DOUGLASS CT Audit #: 7992065 DL Status: VAL Issue Date: 04/17/2014 LDL Status: None City/State: IOWA CITY, IA Expiration 01/19/2022 CDL Cert Excepted Intrastate 522465402 Date: Status: Endorsements: 3 CDL Med None Mailing Address: 322 DOUGLASS Cf Mailing City/State: IOWA CITY, IA 522465402 Convictions Status: Restrictions: Commercial Instruction Restriction CDL Instruction Permit Permit Supplement: Expires 5/7/2014 Date of Birth: 1/19/1959 Sex: F History Information Citation Date Conviction Date ACD Explanation County . UR 07/02/2010 09/03/2010 B64 No Insurance Card '.Johnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. F.ccident Date Case [dumber SUR 04/17/2019... _.. 795317 _... _... IP...... _... Name: Omer, Najwa EI Awad DL/ID: 239CC6458 Pursuant to Iowa Code §321.10, 1, 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 1 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: ®VEkICIf p��Ir 6/2/2015 IOWA a D. 0. T '�-Y 'tBf 6NIYE& - Office of Driver Services �I-un. 1. 'IUI� 4: 31NIV1 0 1 v c CYlM;naI Investigatron No, 9676 P. 5 c. Pr....cicri. - --- _„e -----m. 06/01/2016 11:2. =096 r.v02/002 fpr [ n STATE ,: IOWA Cyftninal History Record Check Request Form �. To: Iowa Division of Criminal Investigation Support Opera(ions Bureau, l" Floor 215 B. 7n' Street Des Molnes, Iowa 50319 (S15)725-6066 (515) 725-6000 Fax I am reouectinw an Tnwn 0,inunal Ni On,v Peened Cheek rnr DCI Account Number: (if applicaDlc) From: City of Iowa Clty City Cleric's office w 410 L.'iVashinv(on Street Iowa City, 1A 52240 Phone: 319-356-5041 rax: 319.356.5497 Last Name (manda(ory) First Name (mandsioiy) Middle Name (recommended) Y11 ` Date of Birth (mandato y) Genifer (mandaEory) Social Securifl, Number (rccomnncndca) OWM 0Male ElFemale -L, Waiver Xnfor>ijahoyt: Without a signed lvaiver from the subject of the request, a complete criminal history record may nol be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, os allowed bylaw, allyays obtain a waiver signature from the subject of the request. WNW Re%eaSe: I hereby give permission for die above requesting offrciel to conduce on lova criminal history record cheek with (tic Division ofCtiminal Investigation (DCI). Any crim4ol hislory dais concerning me that is maintained by the ❑CI may be released as allowed by law. II II WafverSiviature: Iowa Criminal History record Check Results (DC]weonly) As of _-la search of the provided Hume and date of birth revealed: _: v No Iowa Criminal History Record found with DCI a ry ® Iowa Criminal History Record attached, )XI # - _ - � -- ZF DC1 inilials—Pn--- Cr u�1-rr (uaracily) Received Tlme Jun. 1 2015 11')9AM No.E396 L<�-