HomeMy WebLinkAbout15-160�t�ANPWA®40
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-SO40
(319) 356-5497 FAX
1. Name (REQUIRED)
IDENTIFICATION NO. (S�-' ? (0 0
(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
Middle
Last
2. Address (REQUIRED) 0 -5 -DQ ]7 t i 1 k !�?
3. Contact Information (REQUIRED) Email: ��-,16— zc,611 Phone:?/L, :725 r(83
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) o l /,r ( _ 2n Z--(
b. Taxicab Business Name (REQUIRED) C-
5.
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? Al ?4
Type of offense
0
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
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).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
1 hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
Q7, 4 q� �y�� issued on 1r.- � " ' > expiring on,�„ i i z?„ .2 r . I 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 Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant Date
*******kt******k**£'*:FaYk+`*a.xxt-xxx*******#**k+«***s*xf*****fr**k*kki.*xf:f•a•nx********k****3,*f:*+[-.ekx********:F.k**+Y3:*****4:%f*.x**********v-xk**.+-/:*****
STATE OF IOWA )
COUNTYOFJOHNSON )
-l-
CRubscribed and sworn to before me by IAk 1 4o rQtdi r, An this day of
i-�v4�.Sk aOIS 11 ,�
NQttary PuVlic in and for the Stere of Iowa i 131 I i
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 Chauffeur' is se
gnature of P lice Chief 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.
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Kate
CletlgrAxIDRN6ADEAPPL92014amended.Doc 03/2015
Aug. 4. 2015 3:25PM Div of Vrn nal Investigation No.4593 F. 1/2
FYO m:C3irY cr i0we lily Ctcrk �lrioc 08/03/2015 122. ..156 -.—/002
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STATE OFIOWA
Criminal History Recol-d Check
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To: Iowa Division of Criniowl taws(igation
Support Qper4im Bureau, I" Floor
215 L. 71' S)trec(
Des Moines, lama 50319
(515)725.6066
(515)725.6090 irax
I am rCQuesting an Iowa C'ritninal P7 Pnvd rk...rt. n,..
)XI Accotw( Nunikr ._� OO a —F—
Viola;
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From: City Uf,lolaa CTEV. .---,.---.,_------
City Clerk's 6ftsce
410 E. Washington •ts(rCci _W—
tuwa Ci(p, )A 52240
Pbone: 319-356-3041
ral; 319-356-5437---�'•—^---
Fast Name 0„andmp•)
First Dame (n,ondato)
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act '(a d
1
bate 0�} [Ytb bnandelory) �q
(render (nlandaton')
_Social Seceiri ' Number (recommended
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(- C" 1 y
TvTa[e Female
LILA — 1 v -- 33
01(liver Information: 1t%hout a signed waiver from the subject of the request, a eomple(e crinllual history MCord nta)r not
be releasable, per Code of lowa, Chapter 692.2. For complete criminal history record informztion, as allowed by law, always
Obtain a waiver si nature from the sub ect of the re uq est•_
Arafner Release: I Aetnby glre ncnniseien for the above rcgttesting official to conduct an Iowa critnWal history record cheek,vith the Division 0( Criminal
Invrst 916On (DCI), nny criminal hisloty dale eunccming me thnl is maintained 6y Ina UCI maybe released as allowed bylaw.
Winti'erSignature;
4—^
Received Time Aug. 3, 2015 12:19PM Na, 4459
Iowa Criminal Re c(3t°d Check RestECfS
As of a search of the provided name and date of birth revealed:
Na Iowa Criminal History Record favid , du, DC1
mi
® 10Wa Crnnln8l History Record altached, DCI 9
C.
y`
W
'•.r C.'.J
aA
UCJ-77 (06/25n(1)
----
Received Time Aug. 3, 2015 12:19PM Na, 4459
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Office of DrivFr Services
PCI Be,, 42041 Des fddoPn es_ b� �Q306-9204
Phex-,e- 15 234-Ht24I iZO-532-'3'21 ; Faz: 5:5-235-1837
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Certified Abstract of Driving Record
Inquiry Date:
8/6/2015
DL/ID #:
834AK5407 (IA)
Name:
Noureldein, Gaffar Hamid Ali
Class:
D
Address:
2534 BARTELT RD APT 1C
Audit #:
8819945
Restriction
CDL Instruction Permit
Issue Date:
02/05/2015
City/State:
IOWA CITY, IA 522462721
Expiration Date:
01/01/2021
Endorsements:
3
Mailing Address:
2534 BARTELT RD APT IC
Restrictions:
Commercial Learner Permit,
CDL Intrastate Only
Date of Birth:
1/1/1959
Mailing City/State: IOWA CITY, IA 522462721 Sex: M
History Information
Convictions
Customer #:
6260655
ID Status:
None
DL Status:
VAL
CDL Status:
VAL
CDL Cert Status:
Excepted Intrastate
CDL Med Status:
None
Restriction
CDL Instruction Permit
Supplement:
Expires 8/5/2015
Citation Date Conviction Date ACD "axplanation County JUR
02/08/2015 .02/10/2015 M14 Fail to Obey Traffic Sign/Signal lohnson IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
11/22/2014 -- — - 829671 IA
Name: Noureldein, Gaffar Hamid Ali OLID: 834AK5407
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:
8/6/2015
IOWA: ¢'y
). 0. T.
r'•••••''•$`t�' Office of Driver Services
`RRIVt�,_ Iowa Department of Transportation
Name: Noureldein, Gaffar Hamid Ali DL/ID: 834AK5407