HomeMy WebLinkAbout15-200CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
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IDENTIFICATION NO. 15 — SOD
(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 compfefe the "reryuired" information wifl result irk deniaf of the application
Name (REQUIRED) Un if 7 , ¢j e1Et H1��1�
Address (REQUIRED) -7BI yf), 6a [LG j? CA foV4E c: }1 - ') 2-z-cf�7
Contact Information (REQUIRED) Email :jh[A-IlAt mrl e)LtC "I -[ ail)
Cell Phone: 3l g- 3 -4 Z
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) C N�
5. Prior experience in transportation of passengers:.
L
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? r -'A (--)
Type of offense
Where
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended PleadGuil Other
rg
7. Have you been arrested / chaed with any traffic o PnSac in tha_lacf five years? t
Type of offense y� 9
Where When
� O� AA -C Q.,T IU )ALA Sn,n c n- -n lF �A I I
What happened to the chargd(Circle one)
cn
Convicted Dismissed Deferred Suspended Plead Guilty theEg
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five y9l t
-4on Ga
1
Type of offense Where
n,
a -r a
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1"n
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 tat I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
317 i- �1U U issued on 2, , I expiring on of. v 2- i® I understand that if I
falsely answer any questi ns in this application, that this application may be denied. I agree a tmaking 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 -_.�v ,,1• ._ Date
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by 1Q-\C,'r7 c EItl on this _21 day of
the State of
********k*******#*******kkkkk***##*****************kk**###*******##*******kkkkk***************}}*#**********k***********#k****k****#*****#***#*k
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 to o auffeuyS license
Sig natu e o of Ch Of or designee ate
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.
A% tom- _> � -
Sign tore of City Clerk or designbe
Office Use Only
1-2r3
ate
Approved application
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DCI report
State certified driving record
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0312075
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SMARTER i SIMPLER i CUSTOMVF
Inquiry 9/3/2015
Date:
Customer 5460751
Name: Elawad, Moiz Sayed
Address: 701 ARCH ROCK RD
City/State: IOWA CITY, IA
Convictions
Office of Driver Services
PO Box 9204 i Lies Molnes, IA 60.3306-4204
Ph*ane: 516-244-9124 1 W(3-532-9121 i Fay, 516-239-11337
wrvrw. ioatzd ot..aav
Certified Abstract of Driving Record
DL/ID It: 315AE6704 (IA) CDL Permit Class: None
Class: D
Audit #: 9187339
Issue Date: 06/20/2015
Expiration 01/02/2019
Date:
Endorsements: 3
CDL Permit Issue None
Date:
CDL Permit
522452700
Mailing
701 ARCH ROCK RD
Address:
None
Mailing
IOWA CIN, IA
City/state:
522452700
Date of
1/2/1969
Birth:
None
Sex:
M
Convictions
Office of Driver Services
PO Box 9204 i Lies Molnes, IA 60.3306-4204
Ph*ane: 516-244-9124 1 W(3-532-9121 i Fay, 516-239-11337
wrvrw. ioatzd ot..aav
Certified Abstract of Driving Record
DL/ID It: 315AE6704 (IA) CDL Permit Class: None
Class: D
Audit #: 9187339
Issue Date: 06/20/2015
Expiration 01/02/2019
Date:
Endorsements: 3
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Restriction None
CDL Permit
None
Endorsements:
CDL Permit
CDL Permit
None
Restrictions:
ID Status:
None
Restrictions: NONE
OL Status:
VAL
Restriction None
CDL Status:
None
Supplement:
CDL Permit
ELG
Status:
CDL Cert Status:
None
History Information
CDL Med Status: None
dilation nate Conviction Date .dCD Explanation County Jun
)9/17/2011 10/10/2011 S92 Speed Johnson IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
kccident Date
Case Nrimher
7JR
10/31/2010
599546
IA.
)1/31/2015
842701
IA
Name: Elawad, Moiz Sayed DL/ID: 315AE6704
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:
t=romrcir. er ,owm ci. clerk otrlee 31 - •, .� •, ������ �u u.lVOi r. I/)
Y e" 368 E4cev 08/31/2016 16t<u -241 r.w )Go2
STATEGFIOVVA
'tilttin i Tisfarst Record ClIC-ck
y I�egttesf �'c)rnt
I'o: Inwa UivlSiusl of Criminal In V41igalion
8lsppure Opotations 12urCa u, lay Irlour
215 (•;, 7", °it reet
7)es Moines, lnlrg 50319
(575)728.(,066
(515)715-6000 rax
e
I)(:1 Account IJumber: `>'CXJd-
li(applicablc)
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lova Cil , 7A 52T4U
Yhonc; 319-356-8093
Fax: '319-356-S497�`_Y.—_—_--------
nu �utc8 oil:
9t Name (fnandelon)
der (mandator)) --
�f4ele ❑Female
�!—O I — 7 6, 6 Lt —7
„ arcvcr anj
he ror"1170011: �Vithoui a signed w,alver From the Sobiect of the request, a complete Criminal hislory record may not
eleasabto, per Code of town, Chaplet 692.1. For cam le(e criminal biSior)O record Information, as allowed by law, alnays
obtain a waiver si nature from the sub'ecl of Use request,
Wfliver Relente: l l,creb ry
Inveglipalion DC r 8 e o y daision Fol the shove at is Fling o(6ciel to 10 DO l an lwve criminal tall owd by,d dncM wish dio nivision o(Criminal
t p. Any ui(ainel hislory dace cwl6eming me hat is roBbllaihed by the DCI may be released as sllorved by len,
r01Ka L1 tminai 14.sfar Record Check Results
As of q a search of the rov ided name and date :-
p of hirih re�t!r;�led;
v
No lolj-a (:riminal Histm')' Record found with llCy c�
0 I(Jwa Criminal Historykecurd attached, i)(:1 fj
z r.
DCA initials,.._-
Received Time Auz.31 2015 4:32PN No -6939
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