HomeMy WebLinkAbout15-249I 1 -1 1
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319)356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. / r
(Office Use Only)
APPLICATION FOR TAXICAB I MOTORIZED PE
(Police Department review must be made between 8 a
Q
[I1
EFtELE DMER
i�Tp inion Friday)
n-� w
�fal of the ication
FirstMiddle Las
1. Name(REOUIRED) __ tlu''A:,a(o f r✓:�� ��h9i
2. Address (REQUIRED) ta» C1 q C_ ZZ l4 0
3, Contact nformation (REOUIRLI)i Email:, f i'sf h1411 , Ccin Cell Phone:i�31i
{AlPwritten communication sent via email)
4a. Chauffeur's License expiration date ( RLQ 11 RED )
b. Taxicab Business Name (REQUIRED) 1f II t > _ { 11
5. Prior experience in transportation of passengers':: YrAi
6, Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
TvAe of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years?
TVpe of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years?
Type of offense Where When
%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)
0212015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby ce tify at f ave issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
1 /\ L L' 1' 7 ° issued on ,17/jv,l expiring onej i Z I understand that if I
falsely bnswer any questions in this application, that this application may be denied. I bgr6e 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 grant�'ato comply at all
times with all of the provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in frontga Notary Public)
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Signature of Applicant ��;ia al, i� /3iV Date 0
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STATE OF IOWA ) `D
COUNTY OF JOHNSON ) A I
Su'os ribed and sworn to before me by IV CL I uJtL ���1 1e! on this 5 day of
nib �m KELUF K TUTLE ' ` L"�—"� }� "^"
jq F r,�nn rhmme-221sis Notary Public in acrd forthe State Of Iowa
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xRFf t*xSh*kS kxxSxxkx;{i153iA}xhkxxxxxxi.kkkk*S****xki h+xkAiS}Ak**k*}***RkkkkkkRkkkk#kkkk«xk«k*kfi«*xikk*k++*kfx*x{ki.+a Rxs Ai.Ahkhk*Sxtxkx*fh**SS*+***
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 orwelfare of rest
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration/,date of Chauffeur's license 111-7Z oa P-
Sigfinditure 6f PoiffceChief or designee Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YI2AR FROM THE DATE LISTED BELOW.
A&-� P
Signature of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
//Fs
Date
CIeMr Ii_s2oi4r iei��.00c 0312015
OOT
SA.�t4RiE� I SINPtt�i I CUST4ME� t)R14f''� �..®,_..;.A.�...•...�..�;,. � _ ...-.�. �.�.:
Of rce of Driver Servicr>s
PO Box K04, Des Moines, A 503069204
Phoi-ie: E,15-244-91241 800-532-1121 i Fac: 515-239-i 837
wxr+.i0rrada:.3ov
Certified Abstract of Driving Record
Inquiry Date:
6/2/2015
DL/ID A:
239CC6458 (IA)
Customer k:
164046'.
Name:
Omer, Najwa LI Awad
Classi
D
ID Status:
None
Address:
322 DOUGLASS CT
Audit rt:
7992065
DL Status:
VAL
Issue Date:
04/17/2014
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
01/19/2022
CDL Cert
Excepted Intrastate
522465402
Date:
Status:
Endorsements;
3
CDL Mrd
None
Status:
Mailing Address:
322 DOUGLASS CT
Restrictions:
Commercial Instruction
Restriction
CDLlnstruction Permit
permit
Supplement:
Expires 5/7/2029
Date of Birth:
1/19/1959
Mailing City/State: IOWA CITY, IA
Sax:
1-
522465402 522465402
History Information
Convictions
Citation Date Conviction III ACD Explanation County 3UR
07J02/2010 09/03/2010 '.664 No Insurance Card 30hn5on !IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
,:.crident Date Case Number 3UR
04/17/2014 795317 IA
Name; Omer, Najwa EI Awad DL/ID: 239CC6458
Pursuant to Iowa Lode §321.10, 1, KIM Snook, Director of Office of Driver Services, Iowa Department of Transp0rtatien, do
hereby certify that I am the custodian of the records held by the Office of Driver Services, Char 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, 1 have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa
this date:
�y
ryWtlt a�
6/2/2615
D 01 T'�
.c
Office of Driver Services
�.un: 2, '1Uli 4:9IYM Div o1 CYIm10aI Inve:t�.g,at on h0 9676 P. §
-fro- --.. ... •mow- —, C1.11 -- .,Iv —=gym• 06/0112011& 11:¢< some 1.102/002
STATE OF IOWA
CRUniflal History Record Clink.
Request Form
To: Iowa Division of Criminal Investigation
Support. Operations Bureau, 1" Floor
215 E. 7"' Street
Des Molues. Iowa 50319
(W) 725-6066
(915)715-0110 Fax
Record
c
DC] Account Nmnbor:,_ c tom
0l aVVlicaDlC)
From: City of Iowa City �,.--_-
City Clerk's Office
410 L Wash ioglon Street
Iowa City, IA 52240
11houe: 319-356-5041 _
Fax: 319.356-5497
Male (Female 1 X31-- 6Z-3oLi— -L.
Waiver Infornialfon: Without a signed waiver from the subject of ilia request, a casuplete erimina! hisfory record may nal
be releasable, per Code of Iowa, Cbapter692.2. For rGg-rp, lllcte trim trial history record information, as allowed by law, always
Waiver Release:I herby give prrmittion fa de e6ove requcning official to conduce o" lo+eo crimiaet lihtm retard chcd: 05th the Division ofCtiminal
In+xsligeli0n (OCt). Any cfirnioM hislory data concerrdngme chat is "Winoaxd bribe VC] may De aluAd as 31100¢0 by lam'.
Waiver Sts nature:
Iowa Criminal History Record Check Results iDClLire Only)
As of _� a search of the. provided ]tame arid dale of6irih revealed:cr,
T
No lolya Criminal History Record found with DO
® Iowa C:rinainal History Record attached, MI # o
DCF initials
DCI -77 (08125/10)
R a c ¢ I Y e d Time Juh, 1. 2P1i 11;i9AM Na. 6396