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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3191356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) _
IDENTIFICATION NO
110 - I G Z
(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) f n I
19
3. Contact Information (REQUIRED) Email: Q 550.'m RS v WAI
(All written/ communication sent viaemail)
4a. Driver's License expiration date (REQUIRED) d 6 / ZS' 2 O\ 9
b. Taxicab Business Name (REQUIRED) _ - \ i
5. Prior experience in transportation of passengers:
>e �Tlt/ActgL(Q�
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elseggere?�
Type of offense Where en:7
W
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty OtheF
Have you been arrested / charged with any traffic offenses in the last five years?\ J t
Type of offense Where /W hent
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended ead Guil Other
8. 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 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 h by Qertify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
I % i A'C C? Al ( G' issued on %r 1Ak 4expiring on n 0 % . I understand that if I
faIs6Iy`ansWd1r1avfy q es o n 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, nd 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 � Cha hof the City Code. (Needs to be signed in front of a Notary Public)
Signature • Applicant Date 05/
C) g I Z-3 f2 o k
STATE OF IOWA )
COUNTY OF JOHNSON )
scribed and sworn � V - d
sworn to before me by 01a r-s'k-110-1 1 /I on this vJt� ay of
' KELLIE K.
omrnis '�TUTLET
Notary Public in and for the State of Iowa
y o mis on Expires
I'M
R#RltfeM[R*fel,ltN**'#N##tfff#ft#f#fffNNfNf#*tNt*t#fffNNNff#lff+NtlNtltR*H#####HfffNfNfN**N**Ytt1t##1tfNN*NfetttNt#'f*#Miff N*f,IRN*t
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 Drivere 6 �� l 6
rise
C111
ignature of Police 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.
Sign re of City Clerk or designee
A"
ate
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O
Office Use Only C '..� _71
Approved application '— w
DCI report
State certified driving record
Website update
QI AXIDRMW)GEAPPL92014a�. DOC 07/2016
Aug. $. 2016 10:16AM Div of Criminal Investigation No.99h6 N. 1/1
FC_...._. -a V ••s Glen. ..... --- .----�—. OO/DA/2015 OB:'.. J60L 2/OO:Z
STATE OF 10W ' A
' Criminal History Reeord Check
Request Form
To: lowst Division of Criminal Investigation
Support Operations Bureau, 1" Flom•
215 C, TI' Street .
hes Moines, Iowa 50319
(515) 725-6066
(515) 725-6080 Fax
I am resmestinn an Iowa Criminal HiAory Record Cheek on:
ACI Account Number:!�U�ZfG
(iropplicable)
r4on: Cil,�uf Iowa City ,-, �,,,,_,•
City Clerk's Office
410 E. Washington Street
Iowa City, IA $2240
Phones 319-356.5041
Fax: 319-356-5497
Last Name (mandnory)
first Name(mandatory)
Middle Nsime (recommcndw)
ec�
N.)6 YY) -P-A
Date of Birth a owl
Gender (mandatory)
Social Seeuri( '�7Numbeerr (recommended)
Q G g/ 6
Male ❑Female
Cq 9— I G O u
Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, her Code of Iowa, Chapter 692.2• For commle(e criminal history record information, as allowed by law, always
obtalm a waiver si nature from the sub ect of the reqacst.
Waiver 1i eieaSe; i Dereby givepcm+tssion for Ilw above rcqueslin official t eondva an lova criminal historyrecord dock wish the Division otCrimival
nrersnioaliau (PCI). nts)•criroiuel hismq•daw eanccm)ng melhalismain tinedb)'n e"leased as allowed by law.VK
/Q,�
Waiver9gliatur•e: _ Lli (Y'If cv�
Iowa Criminal HistgKy Record Check Results ronumang9
As of _&9-{,6 �, a search of the provided Dante and date of birth revealed: I.;
I f•
lir' No lows Criminal Iiislory Record found with DCI )
r_
❑ Iowa Criminal History Record attached, DCI
DCI initials_ ^'
y
DCI -77 (08/25/10)
Received Time Aug. 4. 2016 8:41AM i.o. 0902
C
Iowa Department of Transportation
Office of Davcr serAces (Toll Free) ODO-532-1121
PO Sox 9204, Das Mol, lA 503D6 -92D4 515.244-9124
ON FA)L 515.239.1837
Convictions
Citation Date
Certified Abstract of Driving Record
ACD
Inquiry Date:
8/23/2016
DL/ID #:
739AJ9915 (IA)
Customer #:
6149393
Name:
Khalil, Mohamed A
Class:
D
ID Status:
None
Address:
1017 20TH AVE
Audit #:
8685599
DL Status:
VAL
Issue Date:
12/11/2014
CDL Status:
None
City/State:
CORALVILLE, IA
Expiration Date:
06/25/2018
CDL Cert Status:
None
522411342
Endorsements:
2
CDL Med Status:
None
Mailing Address:
1017 20TH AVE
Restrictions:
NONE
Restriction
None
Supplement:
Date of Birth:
6/25/1966
Mailing
CORALVILLE, IA
Sex:
M
City/State:
522411342
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
lCounty
JUR
103/11/201-9
104/13/201S
S92
ISpeed
Johnson
IA
Name: Khalil, Mohamed A DL/ID: 739A79915
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:
8/23/2016
IQ'r�IA�
D. 0. T..:
�•i% Office of Driver Services
Iowa Department of Transporation
Name: Khalil, Mohamed A DL/ID: 739AI9915