HomeMy WebLinkAbout16-186� r 1
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
3. Contact Information (F
IDENTIFICATION NO. 1U— 1 p to
(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. Driver's License expiration date (REQUIRED) 0-6_ 2 6 / Un ')-!:2—
b. Taxicab Business Name (REQUIRED)�,�
5. Prior experience in transportation of passengers: - A/n
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When I
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What happened to the charge? (Circle one) vV / 712e / 41 n v
Convicted Dismissed Deferred Suspendedlead Guity -`-7 errnn
7. Have you been arrested / charged with any traffic offenses in the last five years? / r
Type of offense Where -. n
UI
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What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspended Plead Guilty Other
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years
Type of offense Where When
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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)
I
%/0
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department ofTransportati n a valid Driver's license number
7 Q Q r' V Com. Q '7 issued on 2 /0 / 5;4ring on)�nderstand that if I
falsely ans' 1 ker any q estio6i ss'in this application, that this a ccaVi6W rn'ay be denied. I agree a 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)
Signature of Applicant' Y>7 iL Id le 44 Date.�6
N1f 1f HHT T`t#iNN1NNN1f HNIHTH++TNNNHHH1f N11HHHii fl1111N1N1f f NT NHTHf f f f ff 1f Nf1NHf NNNTHHfH«!f f 1T1f fflf f f f f f f f 1f
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscbed Vsworn to before me by �iw,,A e o on this day of
ILR
YYEIVDY S. A111YER Notary Public ' and for the State of lowaf
HTNf«1f Hf f HfHHTMfi111f1tfk«1nMf1.111..YfM1tM1M Rf1-Htf'k1e1-kYf41 Yf4ft...R1t.ltlRklnFfNMffH«ffHM#1tkfMYT41tM
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 Driver's license
Signature or designee
fl/lam
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.
Aas A/ .
Sign re of City Clerk or designee
Date
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Office Use Only
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Approved application
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v
DCI report
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State certified driving record
Website updates
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Cl.r TAXIDRWBADGEAPPL9201"I*r4 tl.DOC
07/2016
FrcAu... g. .30,. - 2016. -.•+_ 1:..08PM.Cl erl. Div ..of _ Criminal—Investigation oan:ar2oles 14:0 L. No.2914 P.-. 1/1
.�-, . .. ..-...�./oo2
STATE OF IOWA�
r`� ttw
ClrbmirmaD Ili.,q y Rfta.Inl Check
Request I Form
To: Iowa Division of Criminal Investigaclon
Support Operations Bureau, l" Floor
215 E. 7" Street
Des Moines, Iowa 50319
(515)725-6066
(515)725.6080 Fax
I am reauestina an Iowa Criminal Histmv )record Cheek nn -
DCI Account Number: qoO ?_ 41
(if applicable)
From City of Iowa City
City Clerl('s Office ~
410 E. Washington Street
Iowa City, 1A 52240
Phone: 319-356-SO41
Fax: 31"56-6497
Last Name (mandatory
First Name pnandolon9
]Middle Name (mcommendcd)
4kwe's
eV -d w`t4 6
P,
Date of Birth (mandala
Gender (mandatory)
Social Sceccurrity Number (recommended)
O- a 6 9� *ale ®Female 2 L l— 0'-/ 77
Dvalverinfbvlrtnfioff: Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 6912. For cam lete crininathlstory record information, as allowed by law, always
obtain Awatversi nature from thesub ectoftherequest,
rr aiVer ReleaS6:1 hereby give pemrission ibr dtc above «questing offmlal to mndur(an Iowa criminal bistoq• record drecic whh Ne Division of Criminal
Inresligation (DCI). Any criminal history duly mnceming nit that is maintained by tht)OCI may be released as allowed by law.
WafVerSignature:
Rolv77a C,rimirkftl Histol' RecoLd (Check Results (UCluse only)
As of �" ) J—� b , a search oftbe provided name and (late of birth revealed: 1
-r
No )owe Criminal IIistory Record found with DCI .r.
Iowa Climinal History Record attached, DCI
r 'l
DCI Initials i
DC1,77 (06/25/10)
Received Time Aug, 24, 2016 2iO4PM No. 2526
-*`-�NUWADOT
SMARTER I SIMPLER I CUSTOMER DRIVEN www.iowadot.gov
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-9124 1 800-532-1121 I Fax: 515-239-1837
www.iowadoLgov
Inquiry
Date:
Customer
8/23/2016
5558422
Certified Abstract of Driving Record
DL/ID #: 379AE8597 (IA) CDL Permit Class: None
Class: D
Name: Ahmed, Emad EI Dine Audit #: 7899906
Bairm
Address: 342 FINKBINE LN APT 9 Issue Date: 03/19/2014
City/State: IOWA CIN, IA
Convictions
Expiration 06/26/2022
Date:
Endorsements: 3
CDL Permit Issue None
Date:
CDL Permit
522461714
Mailing
PO BOX 2044
Address:
None
Mailing
IOWA CITY, IA
City/State:
522442044
Date of
6/26/1974
Birth:
None
Sex:
M
Convictions
Expiration 06/26/2022
Date:
Endorsements: 3
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
Restriction None
CDL Permit
None
Endorsements:
CDL Permit
CDL Permit
None
Restrictions:
IA
ID Status:
None
Restrictions: NONE
DL Status:
VAL
Restriction None
CDL Status:
None
Supplement:
CDL Permit
ELG
No Insurance Card
Status:
IA
12/15/2013
CDL Cert Status:
None
History Information
CDL Med Status: None
-itation Date
Conviction Date
ACD
Explanation
County
JUR
31/23/2013
04/23/2013
B64
No Insurance Card
Johnson
IA
12/15/2013
-01/17/2014
B20
Driving While Suspended, Denied, Cancelled, Revoked
,Johnson
IA
Sanctions
rype Effective End ACD Explanation Occurrence JUR JUR
suspended !08/1212013 03/09/2014 ;D53 !Non -Payment of Iowa Fine SIA ,IA
Name: Ahmed, Emad EI Dine Bairm DL/ID: 379AE8597
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
Office of Driver Services
Iowa Department of Transportation
Name: Ahmed, Emad EI Dine Bairm DL/ID: 379AE8597