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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
1- Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO. /! / 1=j 1
(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
3. Contact Information (REQUIRED) Email: ti „r �, `, t;� j , ,,SII Phone: /� �iIiij
(All written communication sen va-email)
4a. Chauffeur's License expiration date (REQUIRED) t3'Z/ ) Lf-
b Taxicab Business Name (REQUIRED)_. \nwe„n i'�k ;
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
Convicted Dismissed Deferred Suspended Plead Guilty
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
Other
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 1Ume(s)
a
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STA -
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE
You must apply for an individual Department of Criminal Investigation Report (form
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOT
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I h reby cert! that I have issued to me by the Iowa De art nt of Transportation a valid Chauffeur's license number
7i /J(� � d issued on 2q ' f expiring on Q' ` ' 4 lol . 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, .9hapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
I
Signature of Applicant_ T1101,&40l PC6avCen DateO�Vh2z/o20/
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by H cn L+- 7 e_ on this G+ day of
DYE
2�,y � 1r lC�'M Q
onf WENDY S MnYER a Notary Public in and f the State of Iowa
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's license
Signature of Police Chf o signee
� A/Z
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 a# City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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Cron: CitvOrlwvuci[vv
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11 e: 319.316-5041 `--�---
r'e%: 319-356 5497
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ld river XlJforilyaf107r: Wilhoui A signed waiver frorl, the S(Ibjecl ofEhe requesl, a cornplele erimtnal history rocord may not
be releasaGle, per Code oflOwa, Chapter 642.2. rOr con- lnle(e criminal history recol'd information, a5 allowed Gq Iat_ y` May C�5
uGlain a waiver sirrneinre tram !h e_ —SU b ect of the re9uesl. -
1' (fiver Release. I Hereby sive pcnnissiun for
'"csli8ylinn (D(.f). Any r i,illal ld6l0r dato aonn,°"2
n10 11,91 '9line Official 10 hco uun)ou'o criminahlslorywbyorIdHwCh,
et)11,411Ibc DIClSinmained byteI)Cfmhe rtlaered slnwad
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10"'a Recon check
As of (UCI nse Ongj
search ui' the provided natx)e and dale of birth revr'ale(j:
P( Na Inu'0 Cliutinal 1-lislnry Record 1'ow,(i with L)('1 N
loa'a C1 iutinal histor}Record anached, 1)(.111f
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Received Time Jul 29 20155 1,19PN No, W6
10WADOT
SMARTER 15ttAPLER I CUSTUEF DRIVEN wvAv.iovvadot.goy
Office of 9river Services
PO Box 9204 `; Des. Moines., IA 50306--Q294
Phare: 515 244-9124 1 800-:32.-1421 1 Fax; 515-235-1837
wwol dwadat gov
Inquiry Date:
8/6/2015
Name:
Hamza, Mohammed
CDL Cert Status:
Zaielabdan
Address:
2652 ROBERTS RD APT 2C
City/State: IOWA CITY, IA 522462740
Mailing Address: 2652 ROBERTS RD APT 2C
Mailing City/State: IOWA CITY, IA 522462740
Convictions
Certified Abstract of Driving Record
DL/ID 4: 609AH2996 (IA)
Class: D
Audit 4: 8382337
Issue Date: 08/22/2014
Expiration Date: 03/14/2017
Endorsements: 2
Restrictions: NONE
Date of Birth: 3/14/1984
Sex: M
History Information
Customer 4: 5989009
ID Status: None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Iowa Department of Transportation
Citation Date Conviction Date ACD Explanation County AUR
03/05/2015 04/02/2015 815 Speed i IL
Name: Hamza, Mohammed Zaielabdan Dd./ID: 609AH2996
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:
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8/6/2015
IOWA *''�"
D. 0. T.:�%
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9f A. YiR $ate,
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Office of Driver Services
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Iowa Department of Transportation
Name: Hamza, Mohammed Zaielabdan DL/ID: 609AH2996