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Home My WebLink About17-140IDENTIFICATION NO. -7 - I 1 C-) 1 r 1 (Offic& Use Only) CITY OF IOWA CITY APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday) 410 East Washington Street Iowa City, Iowa 52240-1826 Failure to complete the 'required" information will result in denial of the application (3 19) 356-5040 - (319) 356-5497 FAX First Middle Last 1. Name (REQUIRED) Lf &,5Se1 tn A L : I 2. Address (REQUIRED) 37.1 Dot'_2 �A� C =o of a� �� SA '47Z4 6 3. Contact Information (REQUIRED) Email: r l �� t t iQ�o o' �'"� Cell Phone: 9m - (All (All written communication sent via email) 4a. Driver's License expiration date (REQUIRED) b y/ / 7 2- O Z 2— b. b. Taxicab Business Name (REQUIRED) yell o t -J 6n--6 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? No Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? X e_5 Typeif offe se Where ,Spee t✓ao Kce (pes Mo;'r-S) When 0317o If (6 What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? I\j O Type of offense Where When 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please ISrgvide tlgnamq(pi NL) DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE; CER 1iRIED r DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF RGVIEVI[[�T��) You must apply for an individual Department of Criminal Investigation Report (form available uISBn regt). (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 Z C, issued on = A expiring on uj (I I / Zo 7 L 1 understand that if I falsely answer any questions in 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, 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 / 1 t1_1L41 ff L— Date /V Ito / Z c l -I rrarrrrrrrrr::r�rrrrrrrrrraararraeaa::r:rrrrrrrrrrrrra:xar,rrrrrrrrrrrrrrreaaarrmrrrrrr::+:tre�Hmr:rrrrraaarr,rrrarrrr:.earearrrrrrrrraraaar STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by I }u Sc -e � K l.fa f on this �O day of h * . 7 r.1'l 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 Driver's license 1 f -7 / _0 Z 2 Signature &&Abe Chief or designee v� 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 ure of City Clerk or disignee ( \ Date r+a.+rrrrrrrrrr+r.e+r..r..r.rrrrrrrr.rrr+.r:a...:..rrrrrrr.a.+++r.:rkrrrr.r.ea+.eax:rrrrr +++..a-�...rr U Office Use Only '' > n j { Approved application �� v DCI report 1 State certified driving record :'r. Website update r' GeM AXIDRNRADGEAPPL92014amentl DOC 07/2016 C L ClJ10WADOT M www,iowadogov SMARTER I SIMPLER I CUSTOMER DRIVEN Inquiry 10/10/2017 Date: Customer 5422580 Name: Khalil, Hussein M Address: 3729 DONEGAL Ci City/State: IOWA CIN, IA Convictions Office of Driver Services PO Box 9204 1 Des Moines, IA 50306-9204 Phone -515-244-9124 800-532-11211 Fax: 515-239-1837 www.iowadolgov Certified Abstract of Driving Record DL/ID #: 260AD6537 (IA) CDL Permit Class: None Class: D Audit #: 2029678 Issue Date: 08/04/2017 Expiration 04/17/2022 Date: Endorsements: Chauffeur 3 CDL Permit Issue None Date: CDL Permit 522462788 Mailing 3729 DONEGAL Ci Address: None Mailing IOWA CIN, IA City/State: 522462788 Date of 4/17/1971 Birth: EXP Sex: M Convictions Office of Driver Services PO Box 9204 1 Des Moines, IA 50306-9204 Phone -515-244-9124 800-532-11211 Fax: 515-239-1837 www.iowadolgov Certified Abstract of Driving Record DL/ID #: 260AD6537 (IA) CDL Permit Class: None Class: D Audit #: 2029678 Issue Date: 08/04/2017 Expiration 04/17/2022 Date: Endorsements: Chauffeur 3 CDL Permit Issue None Date: CDL Permit None Expiration Date: Restriction None CDL Permit None Endorsements: CDL Permit CDL Permit None Restrictions: ID Status: EXP Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Supplement: CDL Permit ELG Status: CDL Cert Status: None CDL Med Status: None History Information Citation Date Conviction Date ACD Explanation JUR County 03/30/2016 04/14/2016 S92 Speed IA Dallas Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date JUR Case Number 07/25/2015 !IA 870184 02/27/2016 IIA 909902 Name: Khalil, Hussein M DL/ID: 260AD6537 (IA) 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 0. ocomen -at AnkenfTowa this date: o r r— m �ow�wyN.. UJ Y,�r Cl Name: Khalil, Hussein M DL/ID: 260AD6537 (IA) 10/10/2017 Office of Driver Services Iowa Department of Transportation ry : n Cz -- rM .j a ko r cv1. u.j)nivi civ U �Iiminai Invesl19ati0n NO. )VI/ r. I/Z _ — -- clef.. `.,.._— .-.— --11 — e, 10/OB/2ol> is:uo v246 rw,v3/003 . \ -STATIE 1F' V.J'F HMA A l�.0 1nliu�ztl HiStu>i^Y Ree(F,lrd Check TutinwalllvisiwlofC:rlminalYuves(ira(imr 5iup11or( operations Hureau, l's Flmrr 215 E. 711i Slrect Drs Moines, 1MVP 50319 (515)725-6066 (515) 725-6090 Fal: Kka-l.;L of q- /7- Iq W Check HLASSe- IV-\ 1701 Accuunt Number:. - 1 (if applicable) ----- From; City AL City Clerl('s 410 L. �Vashingio St 'a _----.`.--- Cows Com, fA I'hode! 319-356.5041 Fax: 319.756-5497 V�--- QMA)e OFemale ��4Y4LL{{Y tv wnUe[ mcorol LISP 39 Sk3� vvafver,(nJOrnmtlon: Without a signed waiver from the subject of (be request, a complete criminal history record may not be releasable, per Cade Of Iowa, Chap(er 692.2. For con_ tDlete criminai History record information, as allowed by law, always obtain a waiver SWIA from the sub'cct of thc_regnest. Waiver Release; l hereby gi,,t pcnnission for dm above requesting official to conduct en Iowa «iminal history recoN check with the Division of Criminal Invesligalion (DCI), Any criminal history data conceaniog nit lha1 is minlained by the DCI maybe released as allowed bylaw. Waiver Signature; Iowa C>iiminal Histor / ItccorfI Checl(Results As I (DCI use only) of� q I a search of the provided name and date ofbi1111 revealed: No Iowa Crimit)a] History Record found with DCI 5 C) o Iowa Criminal History Record attached, DCI # —3 r 1 sa M DCI initials a 3 � DCI -77 (08/25/10) Received Time Oct. 6. 2017 2:38PM No -8043