HomeMy WebLinkAbout17-157CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040
(319) 3S6-5497 FAX
1. Name (REQUIRED)
2. Address (REQUIRED
IDENTIFICATION NO.
(Office Use ly)
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
3. Contact Information (REQUIRED) Email: -, „ r�$ k�& '7 � (Cell Phone:
(AJI LI � rltten communlcatlon sent via email) -11 1 �� s
4a. Driver's License expiration date (REQ1
b. Taxicab Business Name (REQUIRED)
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? N 0
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other 3
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
Where
When
What happened to the charge? (Circle one) n f ,
Convicted Dismissed Deferred Suspended Plead Guilty Other 1 V / +
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
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIN, EI
�n ti
You must apply for an individual Department of Criminal Investigation Report (form availa'bk`uponn equilft)v
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARO
v 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 alid Driver's license number
7. ,i t�1 I L14 issued on ' . -expiring on I understand that if I
falsely answer any questions in is application, that this app ical tion may be denied. I agree hat 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 SL t AA ?=rp Date JAJ���i_
+wwwrwa»aawr»r»rrr»rrrrr»+wwwwrw»wwrawawwww++r»rasa»aar»ar»r»»r»»rr»»w»»rr»»rrrrr»rr+rr+rrrr»+»»+rrr++»»rr»rrrrrr+rrr
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by A,.z,jca 6. tlawocn on this _ day of
and for the SUte of Iowa
mon
i7_0
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
nS�;-
Signature of Police Chief or designee
L(�? � /l7
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.
Sigfiature of City Cleri or designee
C
)7
Date
C3&VTAXMWBADGEAPPL92019 nnntled.DOC 07/2016
Office Use Only
Q
V
Approved application
b- r
<
DCI report
State certified driving record
co
F`
Website update
i
_V
-v
M
o
Q
N
U
C3&VTAXMWBADGEAPPL92019 nnntled.DOC 07/2016
Page 1 of 1
C1J10WAD0T
SMARTER 1 SIMPLER I CUSTOMER DRIVEN VVVvw.iowadotgov
Office of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9204
Phone: 515-244-91241800-532-1121 1 Fax: 515-239-1837
www.iowadoLgov
Inquiry 11/28/2017
Date:
Customer #: 6564418
Certified Abstract of Driving Record
DL/ID Al: 142AM1447 (IA) CDL Permit Class: None
Class: D
Name:
Elawad, Huzifa
Audit #:
2321400
CDL Permit
Abuelagasim Bakheet
Endorsements:
Address:
342 FINKBINE LN UNIT 3
Issue Date:
11/17/2017
ID Status:
None
Expiration
01/01/2023
CDL Status:
None
Date:
C'7 i
City/State:
IOWA CITY, IA 522461766 Endorsements:
Chauffeur 3
Mailing
342 FINKBINE LN UNIT 3
Restrictions:
NONE
Address:
Restriction
None
Mailing
IOWA CITY, IA 522461766 Supplement:
City/State:
.W
Date of
1/1/1978
Birth:
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Elawad, Huzifa Abuelagasim Bakheet DL/ID: 142AM1447 (IA)
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
0 4
CDL Permit
None
Endorsements:
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
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:
3 ovEquf ,
0 4
11/28/2017
D.
Iyy1®f YBIIII� Sv`F
Office of Driver Services >C•D
C3
Iowa Department of Transportation n�
t
C'7 i
N
C`-)
01)
Name: Elawad, Huzifa Abuelagasim Bakheet DL/ID: 142AM1447 (IA) '<ir1
Z
O�
7[
N
.W
r
0
11/28/2017
RNov•21. 201/, 1:33FR ,.Div of Criminal Investigation No.666U Y. 1/3
--- ---- -- 11/17/2017 16:�. A26v r.Vu2/002
STATE OF IOWA
Criminal History Record Check
Request Form
To; Iowa DlvisionoferlminalInvestiplion
Support Operations Bureau, V Floor
215 Ir. 7's Street
Des Moines, Iowa $0319
(515) 725-6066
(SIS) 725-6050 Fax
DCI Account Number:y Z
(if applicable) -
From: Cil ollowa Cif
City Clerk's Offlee �
410 E. Washin on Street
Iowa CRY, IA 52240
Pbone: 319-356-5041
Fax: 319T56-5497
No Iowa Criminal History Record found with DCIIJ
Iowa Criminal History Record attached, DCI
r-
+ter
--Icxn
0p
r
M
DCI initials
o' ;
9
0
DCI -77 (08/25/10)
Received Time
Nov. 17. 2017 3:10PM No - 0293