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Home My WebLink About16-058CITY OF IOWA CITY 410 East Washington Street Iowa city. Iowa 52240-1826 (3 19) 356-5040 (319( 356-5497 FAX IDENTIFICATION NO. I (C 5 (Office Use Only) APPLICATION FOR TAXICAB 1 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 ` 1. Name (REQUIRED)-SFirst MiddleLast ,Jvvs-AA� C:)Mw 2. Address (REQUIRED) 6-,z9 Ives "wiyW �i � GluJr� cJiy� n i 3. Contact Information (REQUIRED) Email: �iJc�� .['i.cra 4UVIFJM�•�L''Vtell Phone: c� - (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) O ` 1 n�' Z F,^Z'Z b. Taxicab Business Name (REQUIRED) Gi `-S �n 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where r`a When 77 What happened to the charge? (Circle one) _ m Convicted Dismissed Deferred Suspended lead Guilt ,Other Have you been arrested /charged with any traffic offenses in the last five years? -906�6 Type off offense Where When S-1'ced 3.�AVII S'cgV1 A�W4 l 2 > Varj S o h SrCOn 6>-1 I ? I 1 1 ti to the charge? (Circle one) J u S P t `t Convicted Dismissed Deferred Suspended 8. Has your driver's license or chauffeur's license been suspended or revoked in the Type of offense Where AAcI tS Y Other years? A /' (7 When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s) /t f 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 that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number �j/� R -Z 2 issued on i b 1 z_ 1 C. expiring on 'I j ( I )n 2,Z I understand that if false y 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) Signature of Applicant Date 3 1 1 b STATE OF IOWA ) COUNTYOFJOHNSON ) Subscribed and sworn to before me by :_n= uS Sc2, f� u h i on this t V day of IK a -f S�ce+/ Le 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). 0 /0// zoZ -1 Dafe 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. Signature of City Clerk or designee Office Use Only Approved application DCI report State certified driving record '3 Website update ry clerk+rnxioRivaaoceAPPL92014amemed,DOG 03/2015 '• DQT www.iowadot.gov `�.5�#��lE4 (`l?af'i�Eh I f:llSTG;'rEF LIRieE�: Office of Driver services PO Eo:x 92741 Des. Moines. IA h0305-=204 Phone:';it s -244 -91241800 -'32 -*1211 Fax 111-234-1 E37 awx:iovrsdot ow Certified Abstract of Driving Record Inquiry Date: 3/16/2016 DL/ID #: 059AA0923 (IA) Customer #: 1559313 Class: D Name: Omar, Sawsan Khalil Audit #: 9513268 Address: 629 WESTWINDS DR Issue Date: 10/21/2015 Restrictions: IA Expiration Date: 01/01/2022 City/State: IOWA CITY, IA 522462755 Endorsements: 3 Mailing 629 WESTWINDS DR Restrictions: NONE Address: IA Restriction None Mailing IOWA CITY, IA 522462755 Supplement: City/State: Date of Birth: 1/1/1972 Sex: F History Information Convictions CDL Permit Class: None CDL Permit Issue None Date: 31}P CDL Permit Expiration None Date: Fall to Obey Traffic Sign/Signal CDL Permit None Endorsements: 07/11/2012 CDL Permit None Restrictions: IA ID Status: None DL Status: VAL CDL Status: None CDL Permit Status: ELG CDL Cert Status: None CDL Med Status: None Citation Date Conviuiion Date ACD Exp4lnatlorr County 31}P 11/12/2011 12/12/2011 IM14 Fall to Obey Traffic Sign/Signal Johnson IA ]6/23/2012 -. 07/11/2012 - '.592 Speed - :Johnson IA 76/06/2014 07/21/2014 S92 Speed Jasper ]A 75/29/2015 :06/26/2015 -S92 Speed ',Johnson IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. "-accident Date Case Number IDR _. - _.... I1/07/2013 :765805 'IA - .. _ ]4/20/2014 795746 '.IA Name: Omar, Sawsan Khalil DL/ID: 059AA0923 Pursuant to Iowa Code §321.10, 1, Melissa Spiegel, 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: "•••'•;�(rq Vie': 3/16/2016 rrr�F�IlEB$`� Office of Driver Services Iowa Department of Transportation Name: Omar, Sawsan Khalil DL/ID: 059AA0923 State of Iowa Division of Criminal Investigation 215 E. 7`h Street Des Moines, Iowa 50319 Phone: 515/725-6066 Fax: 515/725-6080 Iowa Criminal History Record Check Walk -In Request Your name: jA U( Address: w w' "vt a Ci /State/Zi : 22 Phone #: Requesting an Iowa criminal history record check on: Fill in all shaded areas. Last Name .Iheueto (mandator,) First Name Primer Nornvre (mandatory) Middle Name seg,,.,io Anioibre (recommended) OVA ctYII- UY,(Z' \,-I\ KVO U\ Date of Birth Feclra .Nat nrlenio (mandatory,) Gender Genero (mandatory) Sociiial SecurityNumber (rwommended) 61 -1 2 ❑ Male (_Female Ll bS, Waiver Signature Firma (If the request is on yourself, please sign If the request is on someone else- write N/A) DOI1bONLY Results i As of 1 �5 �� a name and date of birth check revealed: �Io record round " ❑ Record attached DCI # i cr ;. ,< DCT initials 1�� ?� o Receipt Number of requests 1 x 515.00 per last name = Total amount S ( 5,09 Method of payment: X cash money order check # MasterCard or Visa (Last 4 digits) Cardholder's name DO initials ----------------------- -------------------------------------------------------------------------------------------------------------------- Credit Card # Exp. Date DCI -83 (09/09/ 10; Revised 10/ 1 / 10; form reviewed 08/ 11/14)