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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52 240-1 82 6
(319) 356-5040
(3 19) 356-5497 FAX
IDENTIFICATION NO. IIS — I
(Office Use Only)
APPLICATION FOR TAXICAB I 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
1. Name (REQUIRED) i cgi
Middle
2. Address (REQUIRED) ZGFd RnG,o A5 RA -ii i e to vo C. (Ex /69 572.-7 [# 6
3. Contact Information (REQUIRED) Email: orwgt r oIo ji K44Ag= e,��—Cell Phone: ra jo- _� 2
(All written communication sent via email) b c Z
4a. Chauffeur's License expiration date (REQUIRED) d
b. Taxicab Business Name (REQUIRED)
5 Prior experience in transportation of passengers.
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewFiere? o
Type of offense
What happened to the charge? (Circle one)
Where
Convicted Dismissed Deferred Suspended Plead Guilty
T Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
W -013 +^-" D i
What happened to the charge? (Circle one)
Convicted Dismissed
Where
When
Other
When
++
114-1 2vt ?
G-2 r 2 -elf to 14'
Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? / CJ
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
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
�ck t9j:71 4 ( issued on cw-22, Q expiring on v I -22 . 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 o ?: - \Q _ 2�
STATE OF IOWA )
COUNTY OF JOHNSON )
'Xscribed nd sworn to before me by i ! eeJ Jl`kn�Jhis day of
'
I27,T KELLIE K. 700TiLE
C r rani .^in -fume F n2e81 otary Public in and for the State of Iowa
I have reviewed this application, DCI report, and the State certified driving record of this applicant a@ffove �termi that
there is no information which would indicate that the issuance would be detrimental to the safety, h 4tlrbr are of tai -
dents of the City of Iowa City (Title 5, Chapter 2, City Code). c?'
Expiration date of Chauffeur's license
Signature of Police f 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
Date
CIerWT XIDRIVBADGE PPL92014amended.DOC 03/2015
C410WADOT
5MARsTIER 15IMPL Fn I CUITGMF; DPI4E�b +nSJ,€O Git ,C i�;>
Office of Driver Services
PC: Roar 9204 1 Lies Moines, i.A 03k,6-9204
Phone: 5.15-244-9124 1 800 -E -32:-1 12I I Fax 511-239-1837
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Certified Abstract of Driving Record
Inquiry Date:
8/19/2015
DL/ID #:
684AJ7191(IA)
Name:
Seedahmed, Zoelfigar Khalil
Class:
D
Address:
2656 ROBERTS RD APT 1C
Audit #:
7286386
Restriction ';'="
Nge
Issue Date:
08/28/2013
City/State:
IOWA CITY, IA 522462742
Expiration Date:
01/22/2018
iS92
Speed
Endorsements:
2
Mailing Address:
2656 ROBERTS RD APT 1C
Restrictions:
NONE
Date of Birth:
1/22/1968
Mailing City/State: IOWA CITY, IA 522462742 Sex: M
History Information
Convictions
Customer #:
6082387
ID Status:
None
DL Status:
VAL
CDL Status:
Nroge
CDL Cert Status:
N$jB2
CDL Med Stgios:
Nie
Restriction ';'="
Nge
Supplemerrlh
'Speed
.Johnson
IA
10/21/2014
12/01/2014
iS92
Speed
Johnson
IA
♦!:F?L
s
c::x
+'
cfI
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n, -',V'
ConvirtJon Date
ACD
Cxp rn=;hoes
County
J€ IR
11/03/2013
11/14/2013
N63
Driving Wrong Way on One Way Street
Johnson
IA
02/22/2014
03/26/2014
592
'Speed
.Johnson
IA
10/21/2014
12/01/2014
iS92
Speed
Johnson
IA
Name: Seedahmed, Zoelfigar Khalil DL/ID: 684AJ7191
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:
ate'••••'•=�2'4��
8/19/2015
IOWA' za,
D. 0. T.
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Office of Driver Services
"'Sol
Iowa Department of Transportation
Name: Seedahmed, Zoelfigar Khalil DL/ID: 684AJ7191
Aug,14, 2015 4:45PM Div cf Criminal Investigation No.3168 F. 4/1
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410 4;, I,Vaahington .�t.YUCI
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Pax:
a search of the provided name and date of birth
No lova Criruinal Ilistn,y lleco,d found ,lrirh ICI
lov+p �rin3inal llislury Ite.cord aliached, DCI it
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Received Time Aug, 13, 2015 2:25PM %u. 5512
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