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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 3S6-5040
(319) 356-5497 FAX
IDENTIFICATION N0. 11t, _%a'J
(Office Use Only)
7
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 carr, fete #tre "rec uirec"' information wiff result it oeriiaf of the appllcatr"on
Fir t
1. Name (REQUIRED) �t
2. Address (REQUIRED) Gjb
l.
3 Contact Information (REQUIRED) Email:
Middle
Last
<c . ,Cell Phone: !211 grl'A LW
kation sen v�a email)
4a. Chauffeur's License expiration date (REQUIRED) 0' l J tt o j
b. Taxicab Business Name (REQUIRED)_ a-+\( CAb
5. Prior experience in transportation of
. 1, fl /) ,
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
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
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 Ume(s)
c.
cn
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATETIF59D
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CflkK REVIEW
You must apply for an individual Department of Criminal Investigation Report (form availa_6"pgaregt.
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY"""' o
ca
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hgr' by�c ri that I have issued to me by the Iowa De artm nt of Transportation a valid Chauffeur's license number
IS "I—ri a C,6 1, issued on R ' f xpiring on 6' I 1 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)
i
Signature of Applicant. 1 - -,w({ faw Date015&�_,/aE�rJ
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by �' Nn int f tQ Z lA ct r,,Z cam_ on this j— day of
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 world 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 PoliceCp' a signee
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.
Ll
Signatur�re City
/,?-
Clerk or designee
Date
4
Office Use Only
Y\ r
rn
4�a:a
Approved application
-° o
DCI report
_
State certified driving record
Website update
clerUUMIDRIv9ADGEAPPL92014amended.Doc 0312015
FriUI „0� 2015,10: 29 AM Div of Jrimiral lovcsligat,on No 21'119 f. 2/4
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S"'I'.4.TE OF l \YVA
Crilllirlal I-likory Record Checfi
' RegtUA10 Form
'1'w Iowa Djx,Wijj of Criminal Investl(!a l Ion
,Support Optrafi(mv Burrs u, I'� 11om
215 E. 7" Street
fee, Aonines, Iowa .5(1319
(515)725-6066
(415) 77.9-60:;0 Pax
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til Appliwhlc)
Proril: C'ltiv of Iowa City
City Cd;rlds OfCet ...._,.— _
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Phone: 319-356-5041 ---__--
I,ex: 319-356-5497
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IlrrrfVer Xltf7riltCff'011- Without a signed waiverfrom the subject of the request, s complete erim41s1 history record may npl
obtain
releasable, Pel"( -'Ode 0flonar Chapter 692.2. Tar com fete criminal history record information, as allowed by law, ahrayy
obtain a waly_ ca�SiLuafure from the sub ec( pf (he rp9uesl.
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erelense:n�era, ,,,�
We y F peunission for Iha nhove req1 iesiine 0111,611 'a conduce m Iowa Criminal hislory(ceord ch«k Will' the Division
51ig811a1i (Dta). Any orimlllal lei,101) data conol!e/m((in� me Ihae is/�peiiill""reed 6'111c DU MA)' he rclews d at allowed by l:fw, VECrhllind
)'f�fr[1rEl'.s fy liRlG!'E: 11.1909i�cut(' f,�
Iowa Criminal tory Recotd Ctleck gesutt�
IU(A use onlp)
As of _�Tp�p �� �j(�.{ a search fif t11c P1 m,jded (lame and dale of birth revealed:
gyp- NO JOwa CI'ilninal 1-listory Record found with 1)C )
to to Criminal History keeurd auach(d, UC:1
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1,)(')-77 (00'/25/10)
Received Time Jul 29. 2015 1,19M No, 4176
1UWA
www.iowadot.gov
SMARTER I SIMEL F. I CUSTOMER DRIVE' �,�„�.�:�.
Office of Df iver Services
PO Box 9204 1 Des Moines, 0, 50.306-9204
Phone- 615-244-5124 1800-532-11211 Pax: 315-239-1,037
www. Eowadot.gdv
Certified Abstract of Driving Record
Inquiry Date:
8/6/2015
DL/ID #:
609AH2996 (IA)
Customer #:
5989009
Name:
Hamza, Mohammed
Class:
D
ID Status:
None
Zaielabdan
Address:
2652 ROBERTS RD APT 2C
Audit #;
8382337
DL Status:
VAL
Issue Date:
08/22/2014
LDL Status:
None
City/State:
IOWA CITY, IA 522462740
Expiration Date:
03/14/2017
CDL Cert Status:
None
Endorsements:
2
CDL Med Status:
None
Mailing Address:
2652 ROBERTS RD APT 2C
Restrictions:
NONE
Restriction
None
Date of Birth:
3/14/1984
Supplement:
Mailing City/State:
IOWA CIN, IA 522462740
Sex:
M
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
03/05/2015 04/02/2015 '.515 -Speed '.IL
Name: Hamza, Mohammed Zaielabdan DL/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:
>� "••"•y�
8/6/2015
IOWA '0t
D. 0. T. ;
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f•pq$�-'
to
Office of Driver Services
"I „-
Iowa Department of Transportation
Name: Hamza, Mohammed Zaielabdan DL/ID: 609AH2996