HomeMy WebLinkAbout16-068III
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CITY OF IOWA CITY
410 East WashinEton Street
Iowa City. Iowa 52240-1826
(3 19) 356-5040
(319) 356-5997 FAX
1. Name (REQUIRED) _
IDENTIFICATION NO. I --(—) I
(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
2. Address (REQUIRED) -ti4 ?-,L
3. Contact Information (REQUIRED) Email:
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) _�
5. Prior experience in transportation of passengers: _
cqa
Middle Last
I�MAQ flf���
Cell Phone:O 7 :�
nication sent via email) �
29' X62
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? z)t0
Type of offense Where When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
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 prpvide the�i rr s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE`.CERTIFµ'CED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE �i RE)/IEW....
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 her fI h ts to me by the Iowa Department of Transportation a valid Chauffeur's license number
issued on3 �2 expiring on Zk` I understand that if
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 (offf Title 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public)
Signature of Applicant f_ "� Date
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me by G Aneti�� A . iii. M -s A e b � on this �_ day of
Via, ic_lk 'ZoLLe .
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
Sigritatureo Polite �5,brdesignee
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.
7I ��� e��l
Sign e of City Clerk or designee
Approved application
DCI report
State certified driving record
Website update
Date
cy
Office Use Only'
ClerWAXID2IVBADGWPL92014amended Doc 0312015
State of Iowa
Division of Criminal Investigation
215 E. 7°i Street
Des Moines, Iowa 50319
Phone: 515/725-6066 Fax: 515/725-61180
Iowa Criminal History Record Check
\x7..11. 1-.
Your Dame: N1A aIVhA LSU. -•-41 u
Address:
City/State/Zip:
Phone #: 19
ReQuestinp an Iowa cru nival hictnni
Fill in all shaded areas.
Last Name Ape]Hdo (mandatory)
�sOLFr6►
='Non7hre)
Middle Name Szortndo Nmnbre (raeommend{)
AHMA0Date
of Birth wee �2Nae, „�e ro (maoaatory)
Social Seeuri Number remn,endea)
6 I! z
❑ Male ❑ Female
1 J p
U
waiver Signature F'irsna (Lf the request is rni ynunclt; please si�m_ Ifthe request is on someone else, write N/A.)
Results L
o.: oa utrrin�lr
As ofaZ� a name and date of birth check revealed:
r.�
XNo record found _
c -r
❑ Record attached DCI #
DCI initials &e:f
Receipt
Number of requests r x $15.00 per last name = Total amount $ 1 5. C) O
Method of payment: cash money order check # MasterCard or Visa
(,Last a digits)
Cardholder's name
DCI initials
- ---- -----�--- --
---- -'
Credit Card #
Exp. Date : E3
DCI -83 (09/09/10; Revised 10/1/10; form reviewed 08/11/14)
ZlliUWADOT
Fcifii'7E5 151"" '? F I CU:TOM-F DRIV '� _ tNVliiit.IfoWcdot.gov
Inquiry
3/30/2016
Date:
Restriction None
Customer #: 6478108
Name:
Alsuleibi, Emad Ahmad
Mahmoud
Address:
1453 DICKENSON LN
City/State: IOWA CITY, IA
522409163
Mailing 1453 DICKENSON LN
Address
Mailing
City/State:
Date of
Birth:
Sex:
IOWA CITY, IA
522409163
10/23/1972
M
Office of Driver Services
PO bot 9204 Des Moines- IA 50306-5204
Pho-^.e: 515-244-9124 1 t00 -532-i 121 1 r2,: 515_39-1+337
vrwr..icv adot gm.,
Certified Abstract of Driving Record
DL/ID #:
Class: None
Audit #: None
Issue Date: None
Expiration None
Date:
Endorsements: None
CDL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Restriction None
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
ELG
ID Status:
None
Restrictions: None
DL Status:
None
Restriction None
CDL Status:
None
Supplement:
CDL Permit
ELG
Status:
CDL Cert Status:
None
CDL Med Status:
None
History Information
CLEAR DRIVING RECORD
Name: Alsuleibi, Emad Ahmad Mahmoud DL/ID:
Pursuant to Iowa Code §321.10, I, 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:
Name: Alsuleibi, Emad Ahmad Mahmoud DL/ID:
:%syr 3/30/2016
D. 0. T...
.BRIYE9 Office of Driver Services
Iowa Department of Transportation - '3
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