HomeMy WebLinkAbout18-100rr l IDENTIFICATION NO. / R>- J C)(
r = _ (Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
-
CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday)
410 East Washington street Failure to complete the "required" information will result in denial of the application
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(3 19) 356-5497 FAX
First Middle
Last ii
1. Name (REQUIRED) IN— VV01 u- /*,5 s e
2. Address (REQUIRED) L7 2qnp-%CL\ Cit-, 10vya"+ SA 522(
3. Contact Information (REQUIRED) Email: h �� (-7 It Q 4G(h0o • (t, "^Cell Phone:
(All written communicatio sent via email)
4a. Driver's License expiration date (REQUIRED) U `/ vi
�� % / -2—d Z Z
b. Taxicab Business Name (REQUIRED) XC// o w Ca 17
5. Prior experience in transportation of passengers:
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this Stattw elseu; Here? N
Tvce of offenseW here r ens
7<r� o M
Cn
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? ins
Tvce of offense Where When
sp�P�l-es D f30/Zd/6
What happened to the charge? (Circle one)
Convicted Dismissed Deferred Suspend Plead Guil Other
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? NJ z)
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)
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04/2018
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
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).
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
7 E b R (7 y ? % issued on !Loy/> expiring on 0 4/// 7/ Z z . I understand that if
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 /I/���L�v�iT Date 115' -5-13
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by JA r,kct 1 t on this _ day of
L orf - Z��l�•
I have reviewed this application, DCI report, and the State certified drivingrecord of this a lira ' r
pp nZAF ha deter(� ed that
there is no information which would indicate that the issuance would be detrimental to the safety,li�th arafveHare'of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code). __ = 0
Z oExpiration daterQ e' nse OY-17-Z�Z
/0 -ex --2&1d
Sure 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.
Signature of City Clerk or dei nee // Date
•++»»++++r+++»+++»++»+»+»+» m+m+»+»+++m++++++»C.l+»+»++»:+++»+++»+»++++m»+»++»++++++»+»+m+»+»+m++++++» m+++++
Office Use Only
Approved application
DCI report
State certified driving record
Website update
aeiWrNODRIVRADGEAPPL92018am ded.DDC
04/2018
e 'Oct. 2.2016 8:47AM Div of Criminal Investigation
09128/2018 10:46 YeloW Cab
No. 6360 P. 1
ffAX)319 338 2708 P.0021002
STATE OF IOWA
Criminal History Record Check
E Request Vorlxl
To: Towa Division of Criminal Inverttgation
Support Operations Bureau; 1" Oloor
215$. 74' Street
bee Molnas, Iowa 50SI9
(515)725-6066
(515)725-6080 Fax
I am reaucstine an Iowa r`miminn1 CY:.r,..:.1u e......t rt.—..L ..�.
DCI Aocount Number: _.___9967-F
(if opp(lcable)
From: Yellow Cab of Iowa City
P.O. Box 428
Iawa City, IA. 52244
(319) 338-9777
Phone: f _
Fax: (319)339-7302
Last Mance maWw
''First Name (mandatory)'Middle
Naime rcanmmc Wpdj
Date of Birth (mandaroty)
Gender (mandatory
Sorda]-Sowrity Iffimber (recommended
11-711q-7 1
i •0male• ❑FemaleT4--
ri
371
Wadvtr Information: Without a signed walver from the subject of the request, a compiate qrt FAl history rt�Q� may not
be releasable, per Code of Iowa, Chapter 692.2. For complete criminal historyrecord iaformatlenlas ailed by h+v, always
obtain a waiver signature from the sub eet'' f the r uest, i
Walver.Release: I Ywcby give permiraion for the above rrqucsdng ornetal to conduct as Iowa criminal lik"y mead check wld, ft Division of Criminal
Invasds�don (DCI). carry criminar blamry eau ooncemidg mo than maintaiae bytho. maybe mleatcd a}allowo4 bylaw.
Waiver Signalwet _
lowa Criminal History Record Check Results "`` `
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S f"'T
As of d ' 2 r rt
• a search of the provided name and date of birth revoalad::'
No Iowa Criminal HistdFy Record found with DCT
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❑ Iowa Criminal History Record attac�had,',"DCI #1
DCI iWtiais
DCI-77 (08/25/10)
Aa �.iv.d Tim. S.n 1A IAA A 14•dd AAA NA AndQ
C4010WADOT wwa imadotgov
SMARTER I SIMPLER 1 CUSTOMER DRIVER
WNW a 1111w0 eatlon Smbces
po Box 9201 I Des Moines. IA M306-5201
Phone. 515-244-91241 Fax 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
10/4/2018
DL/ID #:
260AD6537 (IA)
Customer #:
5422580
EXP
Name:
Khalil, Hussein M
Class:
O
ID status:
VAL
Address:
3729 DONEGAL CT
Audit #:
2029678
DL Status:
None
Issue Date:
08/04/2017
CDL Status:
City/State:
IA
522462788 �
Expiration Date:
04/17/2022
CDL Cert Status:
None
Endorsements:
Chauffeur 3
CDL Med Status:
None
Mailing Address:
3729 DONEGAL Ci
Restrictions:
NONE
Restriction
Supplement:
None
m
Date of Birth:
04/17/1971
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CD
Mailing
IOWA CITU, IA
Sex:
n —G
1
r
City/State:
522462788
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1
History Information
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rn
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Accidents - Accident involvement indicated does NOT mean the individual was at
fault or given a citation.
Name: Khalil, Hussein M DL/ID: 260AD6537
Pursuant to Iowa code 4321.10, I, Darcy Doty, Director of Driver & Identification Services, Iowa Department of Transportation,
do hereby certify that I am the custodian of the records held by Driver & Identification 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:
Name: Khalil, Hussein M WILD: 260AD6537
10/4/2018
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Driver & Identification Services
Iowa Department of Transporation
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