HomeMy WebLinkAbout15-184CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 191 356-5040
(3 19) 356-5497 FAX
IDENTIFICATION NO. /_ � I ?,tj
(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
First MiddleLast
1 Name (REQUIRED) E[k%tp t1- 9 Mo& NW AtJozn 1 0 yyi
2. Address (REQUIRED) -2153 P eo V i,J n C r/ L 1 (w4,.4 I TA 52210
S Ly
3. Contact Information (REQUIRED) Email: �l",irk a.[Cl71tUfYYIGt x Uwl Cell Phone
(All written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
5 Prior experience in transportation of pa
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? n )n _
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years? 10 n
Type of offense Where When
What happened to the charge? (Circle one)
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? A/o
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= certi that I have issued to me by the Iowa Departm nt of Transportation a valid Chauffeur's license number
�y�� f� �y 1 / issued on irk expiring on10/21 lcj . I understand that if I
in
falsely answer any questions 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 �Itle Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
e
Signature of Applicanf` - = Date 6 2� /�
STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by F_► ; `- _ Aounzr� on this 4JF) day of
S.
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
C_2
Signature of Police Chief or designee
'66<6f7a15
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.l e ice✓
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
ate
ClerkTAXIDRNBADGEAPPL92014ammded.DOC 03/2015
Rug. IL R17 II:j2Aivl Ulv of GrimioaI Investigation No. 2IL P. 1/11
Fv+••v-r � ww ." �%I eY K. vi", 111 opaorai 00/10/2096 13:64 -Ipi r, s/PO2
STATE OF IOWA
CriEfri]121 History Reeolyd Check
Request Fornt
To: Iowa Division of Crilninal bwastigaeion
5uppnrt OPcraiiwm Bureau, I'" Clonr
215 t. 7°i Street
Des Muiites, Iowa 50319
(515) 725-6066
(515)725-6060 Fax
y;JMa�
DQ Account 1Vtnnber: /oc� �2
(if syplicaAle� --- --
Fru m: C:IEY of low,, City
City CIurIPs Office ---.-----"
41U F. �Vashin t[m 5trce[
tots City; IA 52240 _._--- --_--- --
Phone: _ 319-35b-5041
Fax;
owq Criminal History I`teeosc; Check Results
----__-4--
(UCI use nnlrl
As of a search of the provided name and dale of birth revealed:
.
F.
s
No Criminal hlistary Record found with llCl
r'I
�=t
Iowa Criminal IlistorV Recurd attached, llCl f!
L%
DO illidal3 AiuhJ
L C:1-77 (08/25/10)
Received Time Rug. 10, 2015 1:46PIJ No. 5025
Z, UWADOT
5NlA s3TLR I SIMPLER I (U>TOWN DR€Vi %'WWLV.ioVJiicCit3t, 0V
Office of Driver services
PO Box 9304 Res Uloies, 1A 50306-4204
Phone, 515-244-9124 € $OG -532-1121 I `ax: 51 E-239-1837
WWW . iawaoot.goy
Certified Abstract of Driving Record
Inquiry Date:
8/26/2015
DL/ID #:
346AE4411(IA)
Customer #:
4810504
Name:
Hamza, Elkheir Mohamed
Class:
❑
ID Status:
None
Awad
Address:
2153 PLAEN VIEW DR
Audit #:
9057883
DL Status:
VAL
Issue Date:
05/05/2015
CDL Status:
None
City/State:
IOWA CITY, IA 522464450
Expiration Date:
10/02/2019
CDL Cert Status:
None
Endorsements:
3
CDL Med Status:
None
Mailing Address:
2153 PLAEN VIEW DR
Restrictions:
NONE
Restriction
None
Date of Birth:
10/2/1970
Supplement:
Mailing City/State:
IOWA CITY, IA 522464450
Sex:
M
History Information
Convictions
0tation Date Conviction Date ACD Explanation County SUR
09/21/2013 10/08/2013 -F04 Seat Belt Violation 3ohnson IA
Name: Hamza, Elkheir Mohamed Awad DL/ID: 346AE4411
Pursuant to Iowa Code §321.10, 1, 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:
;....... .;r�wi
8/26/2015
IOWA'
rS
D. 0. T.;
c
f®Ni9E&
Office of Driver Services
��.S
Iowa Department of Transportation
Name: Hamza, Elkheir Mohamed Awad DL/ID: 346AE4411