HomeMy WebLinkAbout16-232CITY OF IOWA CITY
410 East Washington Sttcct
Iowa City. Iowa 52240-1826
(319)356-5040
(3191356-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
3. Contact Information (F
IDENTIFICATION NO
/b �a
(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 ,, a 6 t2 2Z
b. Taxicab Business Name (REQUIRED) _ �.e I�rtr +rii - ` « ��A 41 14
5. Prior experience in transportation of passengers: 9A44
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense W here When
/ t4l4 11A S i/krA14(_V CA4
—FLFA ri1—
12 In I' V ? IlilY W Ile 4f Z i% se 14 J 19
What happened to the charge? (Circle one) v 7/ 2d -!
Convicted Dismissed Deferred Suspended ead utty >t3_�er�
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
Where
M
What happened to the charge? (Circe one)
Convicted Dismissed Deferred Suspended PleadGuilty. -ibrthe - -)
c.1
B. Has your driver's license or chauffeur's license been suspended or revoked in the last five ye8rs?
Type of offense Where When �r
n Vl P,4 X lA Se 0+ n4SnJ4, HMT e� w u. Et ri-l(
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the names)
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 (forth 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 Deeppartmmenn-t- of Transportation a valid Driver's license number
�7 Q r S Q i issued on Pn i o^firing on j��g���?4 7'�/�_ I/�ndersfand that if I
falsely an --'mss ue any q es io s m this application, that this a ca i may be denied. I agree fia{ 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 1miL A 14 4 Date 9rGY6
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed al!]� sworn to before me by L rnaQ G ) M;+e )Pn G . r to 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 City of Iowa City (Title 5, Chapter 2, City Coddee)�/�%�7� Q
Expiration date of Driver's license
Signature-oTPolice Chief or designee
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.
2ka ,eu� . ate
Signature of City Clerk or designee
1?//&;l-
Date
Office Use Only
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Approved application
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DCI report
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State certified driving record
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p.vuumnnEIADGEAPricxo„WOVO DOC
07/2016
PryAug....3 0. 2016. w_ .. 1J.0PM ct erl. Div .._ of Crim.inal __Investigation No,�_ae2914a P. 1/1
..,.., _., ........_ _.._e. oarae rxotia rn:x.-.....�roox
.cry ,nenSTATE OF NOWAN�
crimirmat History Cc m oCheck
Request Forl 4C�aj)
Td; Iowa Division of Criminal Investigation
Support Operations Bureau, Tr Floor
215 B. Te Street
Desmolnes,Iowa 50319
(615)725-6066
(515)725.6080 Fax
I am ren nestinse an Iowa Criminal I3(stnry Record Check on -
DCI AccountNtunber: L(pOZ—Y
(ifeppumbie)
rroal: C(ly of Iowa City
City Cleric's Office
4I0 B. Washington Street
Iowa City, IA 52340
Phone: 319-35&9041
rax! 319-3556-5497
Inst Name (mandaicry
First Name (mandatory)
Middle Name (recommended)
V4 e,
Gvrl w `14
Date of Birth
Gondor (mandanny)
Social $ecturiit, Number (mcco mendtd)
Bmandelo
%
*ale ®Bemale
2 67 ! "0 %%
Waiverinjormaflon: without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code oflowa,Chapter 693.l.rorcom IetecriminalhistoryrecordInformation,asallowedbylaw,always
ohtaln0waiver rl aturefromthesubectoftherequest.
Waiver RdfeaSS:I hereby give permtatan 2r dto above requeatinh officlal to eatduae an tow. criminal hiao,yreeord check with IhoDlvLion ofCdanol
Innsfallioa(DO). Any«intival ldslaydalh eoeecmtag melhdi is mainmined by rheDCl may Le rcleWedssallowed bylaw.
W4fvepSfg1?d1lre: kit Q., 1
Iowa Criminal Ristory Record Check Results (Dl:Iureonly)
As of a search ofibe provided name and date of birth revealed:
1•.1
No lewd Criminal History Record found with pCI .r?
® Iowa Criminal His(ory Reoord attached, DCI ' !-
'l
DCI initials i w
A 77 (06/25!10)
Received ime Aug. 24, 2016 MOM No. 2526
Inquiry
Date:
Customer
Name:
Address:
10WAn0T www iowadot.gov
SMARTER I SIMPLER I CUSTOMER DRIVEN
Office of Driver Services
PO Box 92041 Des Moines, IA 50306-9204
Phone: 515-244-9124 1 B00-532-1121 I Fax: 515-239-1837
Www.kwradoLgov
8/23/2016
5558422
Certified Abstract of Driving Record
DL/ID #: 379AE8597(IA) CDL Permit Class: None
Class: D
Ahmed, Emad EI Dine Audit #: 7899906
Bairm
342 FINKBINE LN APT 9 Issue Date: 03/19/2014
City/State: IOWA CITY, IA
Convictions
Expiration 06/26/2022
Date:
Endorsements: 3
CDL Permit Issue None
Data;
CDL Permit
522461714
Mailing
PO BOX 2044
Address:
None
Mailing
IOWA CIN, IA
City/State:
522442044
Data of
6/26/1974
Birth:
None
Sex:
M
Convictions
Expiration 06/26/2022
Date:
Endorsements: 3
CDL Permit Issue None
Data;
CDL Permit
None
Expiration Date:
Restriction None
CDL Permit
None
Endorsements:
CDL Permit
CDL Permit
None
Restrlatlons:
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
Driving While Suspended, Denied, Cancelled, Revoked
CDL Med Status:
None
History Information
Citation Date
Conviction Date
ACD
Explanation
County
3UR
01/23/2013
04/23/2013
864
No Insurance Card
Johnson
IA
12/15/2013
-01/17/2014
B20
Driving While Suspended, Denied, Cancelled, Revoked
,Johnson
IA
Sanctions
Type Effective End ACD _ Explanation Occurrence 31UR ]UR
suspended j0B/12l2013 03/09/2014 ;D53 iNon-Payment of Iowa Fine SIA ,IA
Name: Ahmed, Emad EI Dine Balm DL/IP: 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 Bairn DL/ID: 379AESS97