HomeMy WebLinkAbout16-097T�
CITY OF IOWA CITY
410 East Washinglon Street
Iowa City, Iowa 5 2240-1 82 6
(319) 356-5040
(3 19) 356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO. �J p ` %
(Office Use Only)
APPLICATION FOR TAXICAB l 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
3. Contact Information (REQUIRED) Email:'t 6 rye.( q L'{ Citi r 1us l o rh Cell Phone: 315- -7(07 7
(All written/cI D written nication sent via email)
4a. Chauffeur's License expiration date (REQUIRED) Jb 3 / 2D I, U 4 l iT"C.
f
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers —Ae%? r
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? IN J
Type of offense
What happened to the charge? (Circle one)
Where
When
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? �` 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 naa e(s)
1v o
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REV1�Yli
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
1 hereb certify that have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
y f 1 �� (c J issued on OJ 0 o(Lexpiring on OW-> ZolL . I understand that if I
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 of//TT e 5, hapter 2, of the City Cade. (Needs to be/signled in front of a Notary Public)
Signature of Applicant y Date 51 2 I k�,,
STATE OF IOWA )
COUNTY OF JOHNSON )
scribed and sworn to before me by /ktiLM k-Z-x:D p\j—C on this / �� day of
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 y o Iowa City (Title 5, Chapter 2, City Code).
of g<auff�r's license
or designee
5-.12-1 b
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.
Sig�ture of City Clerk or designee
Office Use Only
Approved application
DCI report
State certified driving record
Website update
ate
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Mo. '9 2016 11:27AM Div of Criminal lnvestigation No. 3772 P, 1/1
From:LIly oY Iowa City Clem UtriC& blvd tl.t$bnb/ 06/04/201e is:,_, Wt Pa r.uu2/002
STATE, ar jGjAi i
Criminal bji.qtoi-y Record Check
•' - req e4t rol-rfl
'rn: rOWA Divisicn of Crim incl lnvestigation
.Smpport Qperatiuns Bureau, 1" Moor
215TL. 7" Street
Ne Mojo(s IOl4a 50319
(518) '125-(-066
(515) 725.6080 FAX
an
DCa Accuunl ] 7umher: __ !gyp
fif applicable)
PrOlo: QY of Iowa city
City CPerlc'A Offiec
470!;. Washington 6trcel
Iuwa Cit , IA ,52240
Phone: _319.356-5041
Fax: 319-356-5497
IVO
Date of Birth (mandmnn)
!render ntanUaloy) SocialSecuri Number
C� '�] �7 0econunendu
u ( , ( � I l❑Female .629-2s- J 4 o S
Rlaiver 11afo"OlatfOlt: 1Vithoae a signed watrer from the subject of the request, a complete crinilnul history record may net
be Obtain
o I a' per Code of fovea, Chapter 692.2, For com,Mete criminal history record informaflan, as allowed bylaw, ahvays
obtain a waiver si nature from the sub'ect of the re nest.
per
'i/ai-,06II MCI). AAt herebygivepermissivn foripeabove requcving ofLeiel In Uo9da wi 101Va criminal hisfoq'record check Will, Vic Division orCrlminal
Inveslipalion (DCq, pny criminal bislory dare concerning nit 4m'ne� by rhe Imay be released as allow ed by lase.
YVazverSPgrvrtfure:_ n r \ � l c
As o1'
PNo iowe C'riwinal J3isfol'y Record found with DO
d town Criminal History Record attached, DCl it
DU
Re
initials__j_
1)C;I-77(08/25110) ~~~--------
Received Time Ma v. 4 2016 4:22PM No 3920
u, urrih 1'evealedi
(irG4pSe only)
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Page 1 of 2
D 0 T
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SMANER I `Ill11-f I CUS10%ii-P DRI VE'd..�,. r1-11 1.1,1—
Office of Driver Services
PO Box 8204 Des Moines. 1,4 50306d>204
Phore:515-244-09241900-532-11121 1 Far._515-235-1837
WWw.10'Nadi gov
Inquiry 5/12/2016
Date:
Customer 6490174
Name: Nour, Ahmed Adam
Certified Abstract of Driving Record
DL/ID #: 998AM1060 (IA) CDL Permit Class: None
Class: D
Audit #: 9981060
Address: 2402 BARTELT RD APT Issue Date: 05/04/2016
2A
City/State: IOWA CITY, IA
Expiration 01/01/2021
Date:
Endorsements: 2
Restrictions: Corrective Lenses
Restriction None
Supplement:
History Information
CLEAR DRIVING RECORD
Name: Nour, Ahmed Adam DL/ID: 998AM1060
CDL Permit Issue None
Date:
CDL Permit
522462703
Mailing
2402 BARTELT RD APT
Address:
2A
Mailing
IOWA CITY, IA
City/State:
522462703
Date of
1/1/1976
Birth:
None
Sex:
M
Expiration 01/01/2021
Date:
Endorsements: 2
Restrictions: Corrective Lenses
Restriction None
Supplement:
History Information
CLEAR DRIVING RECORD
Name: Nour, Ahmed Adam DL/ID: 998AM1060
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
None
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit
ELG
Status:
CDL Cert Status:
None
CDL Med Status: None
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: Nour, Ahmed Adam DL/ID: 998AM1060
5/12/2016
Pte;
a0Clf
5/12/2016
ap y
IOWA
9f'®Ri.� e'er__—=�
Office of Driver Services ,
Iowa Department of Transportation •,
r.p
Name: Nour, Ahmed Adam DL/ID: 998AM1060
5/12/2016