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Home My WebLink About16-158� � 1 ®4 It CITY OF IOWA CITY 410 East Washington Street Iowa City, loiva 52240-1826 (3 19) 356-5040 (3 19) 3565497 FAX 1. Name (REQUIRED) IDENTIFICATION NO. ) I& " it S? (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 First Middle Last j'V .JL4 T 2. Address (REQUIRED) y0� Gtt r ,a -k 2A t 1-a^' 2-Lgk 3. Contact Information (REQUIRED) Email:.fhm� 4 4�=e h/! Ho � cu� Cell Phone: 6. 7 . 35' n (All written commu ication sent via email) 4a. Driver's License expiration date (REQUIRED) j 110 i' '2- L 2- t a 6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? Ao Tyne of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty. Other.�(�/j Have you been arrested / charged with any traffic offenses in the last five years? _ /` Type of offense Where When EC 0 What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended ea�d G lty Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Afrte( Type of offense Where When 9. Have you ever applied to bean 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) 07/2016 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number A �A Ire io issued on " , &expiring on otk 1,21 . I understand that if I fa sely answer any questions in this application, that this a.. Lati n 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 Till 51 Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Signature of Applicant/ Date 1 STATE OF IOWA ) EZ— COUNTY OF JOHNSON ) q Subscribed and sworn to before me by NC".,.r- on this day of KV 4 VSA' '�Jt to N�otabc in and for theme S� t� ate of Iowa , 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). Expirati n ate f fiver's license 1 I r Signatur o Police of 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. 2�4�� 7,K.C)6 gn ure of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update 91'A Date cien,TrxlDRIVMDG� PPLe2maamended ooc 0712016 4= IUWADOT ..-........,w wwwJowadot.gov SMARTER I SIMPLER I CUSTOMER DRIVEN Office of Driver Services PO Dox 92041 Des Moines, IA 50306-9264 Phone: 515-244-91241800-532-11211 Pae: 515,-239-1837 N^ewr-iowadot gw Certified Abstract of Driving Record Inquiry Date: 8/19/2016 Expiration Date: DL/ID #: 998AM1060 (IA) Customer #: 6490174 Office of Driver Services Class: D Name: Nour, Ahmed Adam ID Status: Audit #: 9981060 Address: 2402 BARTELT RD APT 2A Issue Date: 05/04/2016 CDL Cert Status: None CDL Med Status: Expiration Date: 01/01/2021 City/State: IOWA CITY, IA 522462703 Endorsements: 2 Mailing 2402 BARTELT RD APT 2A Restrictions: Corrective Lenses Address: Restriction None Mailing IOWA CITY, IA 522462703 Supplement: City/State: Date of Birth: 1/1/1976 Sex: M History Information Convictions CDL Permit Class: None CDL Permit Issue None Date: CDL Permit None Expiration Date: j1, CDL Permit None Endorsements: Office of Driver Services CDL Permit None Restrictions: ID Status: None DL Status: VAL CDL Status: None CDL Permit Status: ELG CDL Cert Status: None CDL Med Status: None r -a ,7 n Citation Date Conviction Date ACD Explanation County + IUR 07/02/2016 07/15/2016 S92 Speed - Scott' """'q IA Name: Nour, Ahmed Adam DL/ID: 998AM1060 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 su 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: .•"""•:�A1, 8/19/2016 IOWA j1, ). 0. OBonIVER $ - Office of Driver Services Iowa Department of Transportation Name: Nour, Ahmed Adam DL/ID: 998AM1060 State of Iowa Division of Criminal Investigation 215 E. 7" Street Des Moines, Iowa 50319 Phone: 515/725-6066 Fax: 515/725-6080 Iowa Criminal History Record Check Walk -In Request Your name p Lt Y Address: O d Q '1 City/State/Zip: $ 2Z {p Phone #: Requesting an Iowa criminal history record check on: Fill in all shaded areas. Last Name ,4pe111.10 (Mandatory) First Name Primer Nonb,e (mandatoiy) Middle Name Segunio Nombre (recommended) lV o or �./ ri e c4 Ac� -Irt YVI Date of Birth Fees Nuetmae zro {mandatory) Gender ce,re, o(mandatory) Social Security Number (ieaommended) 0 ( tg I I W1 � 19 Male ❑ Female (/ 9 } 2- Waiver Signature Finna (If the re uritis oii witmelf, please sign Ifthe rcqucst is on somciene else. write NA n Is t 11h OILY Results Res alts As of --�7�' a name and date of birth check revealed: No record found Record attached DCI # DCI initials Receipt Number of requests x $15.00 per last name =Total amount $ '50.C)0 Method of payment: cash money order check # 133 MasterCard or Visa Zj�kast 4 digits) Cardholder's name Alir"e& Nou-r w DCI initials ..L --------a<, Credit Card # Exp. Date DCI -83 (09/09/10: Revised 10/1/10; form reviewed 08/11/14)