HomeMy WebLinkAbout16-10911."
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1 Name (REQUIRED) .
2. Address (REQUIRED)
3. Contact Information (F
IDENTIFICATION NO.
(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
4a. Chauffeur's License expiration date (REQUIRED) o I
b. Taxicab Business Name (REQUIRED)__ W
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
When
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended ead Guilty Other
7. Have you been arrested / charged with any traffic offenses in the last five years
Type of offense
C 6t\
What happened to the charge? (Circle one)
Where
L
Ja
Convicted Dismissed Deferred Suspended
When
Other
1Z -moi 2�t3
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? N
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 name(;)
fill f1 t_.
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 uporuequest).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
Ifm� jel
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
Zssued on a -7 I xpiring on r-1 .) Z . I understand that if I
false/ answer any q estions in this application, that this application may be denied. I agr a 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)
r
Signature of Applicant v h o f"1 Date 6 ?
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed .� Q_ and sworn to before me by Q_�ti o (� y�� on this day of
I t . 7,t1! 1 n
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 t } r f tol Q 2
_JI jc�s D(ao-7t(0
Signa£ure cY Polka Chief or designee 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.
) it., -kl • -eet�
Signa of City Clerk or designee
Approved application
DCI report
State certified driving record
Website update
ClerkrrAXIU RIVBADG EAPPL92014amended. BOC
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Date
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Off' U O I `_ m
ice se n y
0312015
C'DoT
i .: xrE t,:_,tnrlrici�iv
Office of Driver Services
PO Box 1244 I Des Moires, IA 50306-9244
Phone. 515-244 1800-532-1121 i Fay,: 515-239-1837
ww.iowadatgor
Certified Abstract of Driving Record
Inquiry Date:
5/31/2016
DL/ID #:
239CC6458(IA)
CDL Permit Class:
None
Customer #:
1640461
Class:
D
CDL Permit Issue
None
Date:
Name:
Omer, Najwa EI Awad
Audit #:
7992065
CDL Permit
None
-
C?
Expiration Date:
Address:
322 DOUGLASS CT
Issue Date:
04/17/2014
CDL Permit
None
Endorsements:
Expiration Date:
01/19/2022
CDL Permit
None
Restrictions:
City/State:
IOWA CITY, IA 522465402
Endorsements:
3
ID Status:
None
Mailing
322 DOUGLASS CT
Restrictions:
Commercial Learner Permit
DL Status:
VAL
Address:
Restriction
CDL Instruction Permit
CDL Status:
None
Mailing
IOWA CITY, IA 522465402
Supplement:
Expires 5/7/2014
CDL Permit Status:
ELG
City/State:
Date of Birth:
1/19/1969
CDL Cert Status:
Excepted Intrastate
Sex:
F
CDL Med Status:
None
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
At ident as::, Cane Id Urar l: r 3UR
04/17/2014 795317 IA
Name: Omer, Najwa EI Awad DL/ID: 239CC6458
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: Omer, Najwa EI Awad DL/ID: 239CC6458
...... p7.
.7i
5/31/2016 --
_
IOWA'::';
D. 0. T.:�s'
291r"••••"$�_
Office of Driver Services
�s......
Iowa Department of Transportation
j:
-
C?
Name: Omer, Najwa EI Awad DL/ID: 239CC6458
Jun. 3. 2016 12,I9PM Div of Criminal Investigation N'0.5593 P. 3
FrgtrrI!u1TY o[ Iowa Guy Mark Orrice 316 SES6497 o5/a1/2018 10:30 b629 ).002/002
STATE OF IOWA
011111 1T$l History Record Check
Request Form
Tn. l(Jwa I)!'11M))'of Criminal fnvcrgjgation
Support 013er3f16n5 1'5ureaE,, 14' Y.[,)
21511. 7" Scfeo
Des Moines, rosl+a 50319
(515)'125-6666
(515) 725-6000 Fax
!.ani requesting, all
UC 1 Account )Jun)bcl':
(if applicahlc)
from: My gjolvaC
C'ify Gerle's (3ffice
41011. Washin lg un Sty-
Iowa Ci(y, IA 52240
Phone; 319-366-5041 _
Fax;
�� I ❑A'fale LJ(�'emBTe I
_ �?
W[[1Ver %r[tf0Y17[rz/%Ofd; �Wilboul aeigned 1a'aiver fl'em the subject of the request, a Complcle criminal history record may not
be releasable, per Code of Io[va, Chapter 692.2. For comaleee criminal history record information, as allowed by law , always
obtain a waiver si nature from the sub'ec[ of [he request.
Wd{VBT Rele(Ise; 1 hereby glee pemli"ion For the above requesting official to eooducl an low, criminal Isislory rotord clmIk n-0dr ibe Di
h)vesligalion (Dcl) Any ariminnl hiaory dale copccrning me [Ila[ is meinl med by Ilse DCI may be rcltoscd ss a)le V,d by law. vision a f Criminal
Wr[iver S'igrxr[[ure,
search Of the provided name and dale of bird, retreaded:
No Iowa Criminal ifistory Record found with ll('1
Jnaa C'siwinal ldis(Dry Record attached,lJC1
DCJ-77 (08/25/1 0) -- — —
Received Time May, 31. 2016 10:15AM No. 6458