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CITY OF IOWA CITY
410 East Was hinglon Street
Iowa C�owa 52240-1826
C=5040
(319) 356-5497 FAX
1S ;� 0,3
f� - Authorization Number I__
' m e rn it, X (Office Use Only)
APPLICATION FOR TAXI I MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday— Friday.)
Failure to Corrrplete the "required" information, will result in denial of the application
1. Name (REQUIRED)
2. Mailing Address (REQUIRED)
Middle
Last
3. Contact Information (REQUIRED) Email:1�Cell Phone:
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where tVhen _�
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol ol indhe last fye
years?_ AO
Type of Offense
Where
7, Have you been convicted of any traffic offenses in the last five years?
Type of offense
Where
When
When
8, Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
Tyne of offense
Where
When
N4
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).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
0912014
I hereby certify that ave issued to me by the Iowa Department of Transportation a valid Chauffeur's license number,
a d� . I understand that if I falsely answer any questions in this application, that this
i
application may be denied. I understand that if I falsely answer any of the questions in this application, that this application will
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 1 further agree that, if a license
is granted, to comply at all times with ail of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public) m
Signature of Applicant dADate j 5 2Q t
YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY
CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org.
i***F*t;;%*%*;;#il*R*X*uSktrkY4'Xfiii3*ti.}i*k4*#„**iRtRRR****R*tk*+RR.1-hkkYit4kY!!k*rtwkrt##n.'riw*pRkM:*Rh*kkk%%%**%%#**h*4*iii;*M*h!*4.1****i;*!**i4f#*
STATE OF IOWA J
COUNTYOFJOHNSON )
Subscribed and sworn to before me bytiOn this J J day of
No rj-'ublic i and for the State of Iowa
'5 l3(fl
i**ki*;k#k***#F*k*#zkkx#h**kih*i**t*%rt*kkk***k*kk*%**xtxkztxkt`YkktYt;k*;k;%Xkkkk*itkkR*tR*R**xrt*k*kk*i*****Oki*iktk*k*i*ik**4**1k*sstx***x*xa%*x;
I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there Is no information which would Indicate that the issuance would be detrimental to the safety, health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
i •6116 Sign2ftLjre4jefor sign—eel
Date
YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY
CLERK'S OFFICE, Authorized taxi driver names are placed on the city website at icgov.org.
T I
Signature of City Clerk or designee
Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8'W1(width) and 5'/z"
(height) and prominently displayed to all passengers.
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e 'A cW Office Use Only
r
Approved, pplicatip . 'Y
DCI report ,
State certifieddrivingrecord
Website update
cia.*n Doc 09/2014
=.n. 2_ 201 ii 10: 15.01 Div of Crir:inal Investiaatic�y
Crrvmi n,O ELNIOTY kecord Check
----
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DCI AcanuntNUm6er:
{If appllcPtde)
Glom: CI(y of Suwa City
CRY M1`109 Off'IC45
4108. Wuhing4on street
rowa City. TA 53240
1111one: 319-336-5041
Fox, 3M356-5497
middle Name
N aid iV1
1TygiV¢r rh]forftfu(ion: Wttbout a signed waiverfirom tho suhjcct of the request; a complete criminal hls(ory record nlgy not
ha rolegsubla, per Carly. of Iowa, fhaptcr 692,2, Izor completecriminxl hkWry record inforrnatlou, as allowed by late, always
obtain a waiver Agnature from the subiect of the rearrest, ,
WaiverPelease:Ihcrcbygivepc=Tssionforlim-SovalequesilogofrIPIwwndactMIowacrfnstnelhhiuryru rdohe4unktheD1vlrlehofCdhl(nal
InvrsllgeAan [Del). Any ctirolnel Msuxydat01 =1w inghl r tic alnlaroea by lho DCl may be relayed is dlaN cd by lwy.
wafverSigluil`ure:,LL 2 Uig
Iowa Criminal History Record Check Re,juIt
As oft2%I `_ r _ , a search of the provided umue and date of birthfevealed:
IYJ No Iowa Crinrinal History Record £oundwith DCl
0 Iowa Criminal History Record attached, DCI #
I DC hitials—b-It—
Received Time—De c, 3i. —2014-11:04ANI—th )177
i)ni.,77 (ngollln)
Page 1 of I
DOT
Office of Driver Snrvinns
On Po °204 Des Mom.", ;A 5D ,5-92(;4
A Acv A -w a:_d goy;
Certified Abstract of Driving Record
Inquiry Date:
12/31/2014
oll S:
732AI6748 (IA)
Customer #:
6138609
Name:
Ismail, Ahmed Hassan
Class:
D
ID Status:
None
Address:
2363 WHISPERING
Audit S:
8729082
DL Status:
VAL
MEADOW DR
Issue Date:
12/31/2014
CDL Status:
None
City/State:
IOWA CIN, IA
Expiration
05/02/2016
CDL Cert
None
522406806
Date:
Status:
Endorsements:
3
COL Ned
hone
Status:
Mailing Address:
2363 WHJSPLRIr4G
Restrictions:
NONE
Restriction
Ncne
MEADOW DR
Date of Birth;
8/2/1970
Supplement:
Mailing City/State:
IOWA CITY, 1A
Sex:
M
522406806
History Information
CLEAR DRIVING RECORD
Name: Ismail, Ahmed Hassan DL/ID: 732AJ6748
Pursuant to Iowa Code §321,10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do
hereby certify that 1 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
1 ransportation to so certify.
In witness whereof, I have caused my signature and the seal of the Department tD be set upon this dnrument, at Ankeny, Iowa
this date:
Name: Ismail, Ahmed Hassan DL/ID: 732AJ6748
12/'1/2014 /
C491V l�
Office of Driver Services
Iowa Department of Transportation
12/31/2014