HomeMy WebLinkAbout15-057Authorization Number
(Guice, U i3nly}
Ccpl-1 / ....
APPLICATION FOR "I" II f MOrl'ORIZED IPILIDIttAB WHOLE DRIVER
(Police Delpairtnmennt review must Ilse armada between 8 &rn„ to 3 IP.nm., IMounday.w- Friday.)
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First
1. Name *,
3. Contact Informaflon (I,REWl° ED)
4. Prior expae6ena lin transpoatation of
M
Cela Phone'.
5, Have you ever been convicted of any misdemeanorsand/or-lo i k
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6. Have yobpe
u
years? convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
7. Have you been convicted of any traffic offenses in the last Five years? _..._......
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8. Has your driver's license or chauffeurs license been suspended or revoked in the last its yea
n�ygta avG t' ui4 Rta:¢at3Yh
You must ap for . I I lXL;V.l,. s+.«"a ! ,�•, y ;'1, / f � bxG�!
`4 `. ,� { . � i � 111 ♦; i l: ! v '� ♦ f4' ',:!t.
of a Notary to be signed In front
Public)
Signature Of Applica
Date
I2-015
"M61 -11M I Feb W77thIrool 11 kLI If
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STATE OF IOWA }
CUTYOFJOSON 1
Sua a bedandint to before one by c,\ , , � spa a,. tl of
On this
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reviewedI have DClMreport, and the State cerfiff
o . 'en .
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or designee D— --
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ais
Taxi businesses are required to Provide Driver
H and 5 W1
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4 �1
Approved application
DCl report
certifiedState driving record
Websiteupdate
fi.5i' �Q%{,f'.��pIN3yViVXi i}Od` 0912014
Page I aro.
77
Inquiry Datm
1/8/2015
DL/218 M
249AD2618 (IA)
Customer *:
5410029
Name:
Osman, Adll M
Claus:
D
ID Status;
None
Address:
102 WESTSIDE DR
Audit d:
6455092
DL Statuso
VAL
Ksous Derain
11/08/2012
CDL Status:
None
city/State:
IOWA CITY, IA
Expiration
10/26/2015
CDL. Cert
None
522464356
Dates
statual
Endomemenizo 3
CDL Med
None
Status:
Mailing Add
102 WESTSIDE DR
Restrictions.
NONE
Restriction
None
Date of Birth:
10/26/1969
Supplement:
Mailing Clty/Ststm IOWA CnY, IA
Sex:
M
522464356
=rU
Citation DtulGe
Unvrciotiou Dater
ACD
Exp8atiawlultlon
County
SUR
6"7127/'2Q116
10/0112010
41u92
Speed
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1t0/29/20IIl . �
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Daslhrce nue
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IA
Transportation to so certify.
In witness whereof, I have caused my signature and the seal of the Department to be set upon this documeW at Ankeny, Iowa
this date:
.rrn
a..» 0 1/8/2015
CV!!K4w
��
e ose^" oa of Driver Services
Iowa Department of Transportation
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Jane6, 20y155 9; 11NMA Div of Crim nal Investigation No, 7373 P, 1
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aaiver nforaatae/da .^ wuhant a Signed waiver from tho sabjw.aq; ertho reclutst, a eomplate arRtrraRAaml blidary record many net
laeregeaaawo, per Cad* of lowta, Ch„ ptor M1 Feryewau Rate criminal Iggslew.;y raeer4Inforumarlon, as altowed by law,alrwaFa
Waiver ReAMPse,Ah"aI.repwap1,,,e+Rm&AAwdR*aheV* ..qd&'
Ru, udgmaromMCQ..wpnywhium9hidwyA%"mammbsmeIIIRi,ghu
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qn ma,mdiark mare Yo4bm,;6tte,RaBq VogsRe� xKd mllsmk wtn'Vga aR,mAFRvfuxenm mrd."Vi,eknmp
s Ohr DO magr ha r,Rmmad as Mkwaaa by Ram.
To rt Criminal Histill 111 ily Record Chec "ItO��S
.As of ` (- Is a scoralt of fho,pro'9ialed.. rR ° and date Of bhtln
Tok leo .Iat as 0iru in al :hist R000rd fasgmnal °th'DCl
NA low& Criminal :MtoxyRecord Attached, l}t.""l
JD ba141als,
Received ui e-Jan,l5.-2015— 1A5PM-No,'133T
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To; Xowa Dtvislou of Criminal Investigation
Pramt Q«K¢ of Iowa C¢ Y
Support Operations Ilureas, l" door
city tnloriea c mea�p
316 E, 71h street
X610 X `4 a,sh6,a0Vara'St t
Dog 1„ ea,,Cowa 60319
(515) 726-6066
(515) 72&6080 Fax
pitons¢ °q:19-�9 a6 -506A.
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aaiver nforaatae/da .^ wuhant a Signed waiver from tho sabjw.aq; ertho reclutst, a eomplate arRtrraRAaml blidary record many net
laeregeaaawo, per Cad* of lowta, Ch„ ptor M1 Feryewau Rate criminal Iggslew.;y raeer4Inforumarlon, as altowed by law,alrwaFa
Waiver ReAMPse,Ah"aI.repwap1,,,e+Rm&AAwdR*aheV* ..qd&'
Ru, udgmaromMCQ..wpnywhium9hidwyA%"mammbsmeIIIRi,ghu
I�Rf 9maaiurM r q,
qn ma,mdiark mare Yo4bm,;6tte,RaBq VogsRe� xKd mllsmk wtn'Vga aR,mAFRvfuxenm mrd."Vi,eknmp
s Ohr DO magr ha r,Rmmad as Mkwaaa by Ram.
To rt Criminal Histill 111 ily Record Chec "ItO��S
.As of ` (- Is a scoralt of fho,pro'9ialed.. rR ° and date Of bhtln
Tok leo .Iat as 0iru in al :hist R000rd fasgmnal °th'DCl
NA low& Criminal :MtoxyRecord Attached, l}t.""l
JD ba141als,
Received ui e-Jan,l5.-2015— 1A5PM-No,'133T