HomeMy WebLinkAbout15-118r
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 3S6-5040
(319) 356-5497 FAR
IDENTIFICATION NO.
(Office Use Only)
J
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
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1. Name (REQUIRED) _--GIt)iQ1r1
2. Address (REQUIRED) 4CpA-”
3. Contact Information (RE -QUI RED) Email:
4a. Chauffeur's License expiration date (REG)UlREC
b. Taxicab Business Name (REQUIRED) r lin u/
5. Prior experience In transportation of passengers:
C
1
he Cell Phone:
via email)
6. Have you ever been arrested /charged with any misdemeanors and/or felonies in this State or elsewhere? Alb
Type of offense Where When
v t°
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7 Have you been arrested I charged with any traffic offenses in the last five years?..-,— �j'�ry
Typeof offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? 410
0
Type of offense
Where
When
9. Have you ever applied to bean 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 Crlminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
0212016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page. 2
I hereby cWX al 1 av issued to me by the Iowa Depa t (C?r sportatlo I' Chauffeurs license number
C� 2 issued on I { xpinng on��. I understand that if 1
falsely answer any questions in this application, that this application may be denied. I agree that in making this application, I
consent to alknv 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 r r o n n•� �. Date
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STATE OF IOWA )
COUNTY OF JOHNSON )
me by t r r ) ( 6 on this }< i + A, day of
of Iowa
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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).
_
Signaturo of Pal' or designee — Date
4
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.
THE EFFECTIVE DATE WILL MATCH THE CHAUFFEUR'S LICENSE EXPIRATION iF LESS THAN A YEAR,
Signature of City Clerk or designee
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Office Use Only
Approved application
DCI report ----
State certified driving record -
Website update -
Ua AMRIVBPDOEMPL=4WA1116dO 0212695
Feb. 26.
2015.
11;13AM
Div at Criminal Investigation
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STATE OF IOWA
Criminal History Record Cheep
10 Request Form
To: Iowa Division of Criminal Investigation
Support opara tions Bardau,l"Floor
215 & 7m street
Dia Molnar, Iowa S0319
(515)725-6066
(515) 715-6080 Fax
I atan nquasting an Iowa Cr-lrninal klistoty Record elmok on:
No, 1210 P. 1/1
No. h6bd r. 1
DCIAccoimMiraber: Ll�'-F
(Iferplioebie)
From: City oflowa �1x
City Clerk's office
410 E. Washington Street
Iowa Ctty, 1A 51240
Phone: 319-356-5045
Fax: 3I9+956Sd97
iaattXalaaapnaaearnrr MrstName (mwdaeo TfiiddlelVaduB racommebed)
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DAN OfBirth (mWWOM Gender (mandawh Socia1l jjSeecuri NumQber (rMS—+11
commanaed
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DMAU al BinatO t✓� V r V" S- q 1
WlffVer,( Orlttatfep; Without a elgnad wa(verllom fheaabieat of the request, a completa crltnlnal hlMtoty record may not
be releasable, per lode of fawa, Chapter 692.2. Far com to erlminal blitory record lnformstion, ea allowed by law, always
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WaiverReleam hmabygiveImmanionforamaboverep eWaiga"tocanduotmTomor(mlaalIdnayreoard�heekwahMeDNManartxiauaa
1nv*1pdcnM. Any alnbm114simydalaeonrolnlname$betbtnahtalr-dbyMeDOmoyberdemadaaKorxdbylaw.
Waltversegmat"m
Lova Criminal Mstorw Record Check Results
As of —110 1 � a search of the provided name and date of birth revealed:
Nb Iowa Cirindnal history Record found with DCT
® IoWa. Criminal History R=ord attached,, DCI #
DClinidals
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Received lime Fit 5. 2015 2:06PM No, 1119
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Office of Drivft sarwc"
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Certified Abstract of Driving Record
inquiry Date:
3/4/2015
DL/ID ft:
059AA0923(LA)
Name:
Omar, Sawsan Khalil
Claw:
D
Address:
1001 N BOSTON WAY
Audit Or
7358065
Restriction
Norse
Issue Date:
09/19/2013
City/State:
LORALVILLE, IA 522413116
Expiration Data:
01/01/2016
1542.,
'Speed
Endorsements:
3
Mailing Address:
1001 N BOSTON WAY
Restrictions:
NONE
Date of Birth:
1/1/1972
Mailing Clty/State: CORALVILLE, IA 522413116
Sex:
F
History Information
Convictions
Customer S:
1559313
ID Status:
None
OL Status:
VAL
CDL Status:
None
CDL Cart Status:
None
CDL Med Status:
None
Restriction
Norse
Supplement:
I'
CiCAjon "Vote
Consiction Date
ACD
enpianation
Count;•
X)R
!1/E2j701E
'12j12f2011
N14
Fall to Obey Traffic Sig n/519
"Johnson
IA
;S92.
Speed_ .. .. . "... _.... ,
,..... Johnson
.IA
06{0612014
107/2112014
1542.,
'Speed
.Jasper
ilA
Accidents - Accident Involvement Indicated does NOT mean the individual was at fault or given a citation.
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1 110 ._. _ IA _ F
04/20/2014 .... €795746
Name: Omar, Sawsan Khalil DL/ID: 059AA0923
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 retards 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:
.Flrff
.••' a
8)4/2015
•�
Office of Driver Services
I[Alk�
Iowa Department of Transportatlon
Name: Omar, Sawsan Khalil DL/ID: 059AA0923