HomeMy WebLinkAbout14-219„�► :1:111 *'
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
317 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED)
2. Mailing Address (REC
Authorization Number
t�t (Office Use Only)m
APPLICATION FOR TAXI / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.)
F,'2�tai,c ¢ah'iformadorl...will ra�.�,U1 ire-c(a�Wa1.asf,9he,platadcl,��ea�aa
3. Contact Information (REQUIRED) Email: Gtelv;n. aC 2.'TC1 f y 3pyietZ, - cewt Cell Phone: ff- e 77 P 6A0 -
4. Prior experience in transportation of passengers: • n
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? A/0
Type of offense
Where
When
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?
Where
7. Have you been convicted of any traffic offenses in the last five years? -
-ALP--
Type of offense
Where
mm
When
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? y� .
Tvpe of offense p Where ® When
,"c3WCt Cat T
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
E7 -
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CFRTIFIElb
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEPSWVgV 1„1
You must apply for an Individual Department of Criminal Investigation Report (form ava)lable'gponWquet '
(OVER FOR REQUIRED SIGNATURE AND NOTARY) I
09/2014
hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
r q f„F""" . I understand that if I falsely answer any questions in this application, that this
,.
applica ion may be denied. I understand That if I falsely answer any of the questions in this application, that this application will
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 a license
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 srcrt
of a Notary Public)
Signature of Applicant g, wt 11 �M,.9 � �"' ••-" Date f ® +
YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY
CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org.
STATE OF IOWA )
COUNTY OF JOHNSON )
S bscribed anc� sworn to before me by ray v� � W � W� a� w •a �' •r to m"e t On this "�% _day of
t°�.
fp �.
ybII4 in and for the State of IouGd
1 have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the Issuance would be detrimental to the safety, health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
Signakeof13o oj designee
- /—/
Date
YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY
CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org.
SignMure of City Clerk or designee
/cz ^/
Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 %" (width) and 51/2"
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
��w"......
State certified driving record
Website update
ClerkrrA%IDRN&4DGEAPPL92014amwdedDOC 09/2014
SeP. 30. 2014 11:20AM
Sep.25. 2014 11:55AM
mo
mo
mil mill
Div of Criminal Investigation
CA y Clerk City of Iowa City
STATE DL 1OVVA
'fob Iowa DIwAsIonofCyA Inn bveMpHon
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21.9 .R 70"9tmvt
Groes Maims, Town ,50319
(9.18) 9.�-6066
(915) 124-6080 •6080 Faze
No, 0875 P. 1/9
No. 5135 P. Z
G C1 Accoamwt lgiun.hoG.._
QiiPn}tplNanHYoj
City Ck des Office
«4:ft® .,WalkhNIga tLeet ----------- _.__
Ic aaa Cit t ISS 5---------- _._— _ _____„
I'7Xqum 51.9-.356-504Il
Fain 319-3.564491
�&) $ Q;IIII�BA IustoI"y jeLecom q.e,Ifly(K mcuBA.A.N.kA (DOIuse only)
As
a search of tho provided name and date of birth revealedr c.
No Iowa Criminal History Record found with DCT
Iowa. Criminal fflstu7 Record attached, :CCI_._.___._._,._____ .,
DCl
AN:ATi;S Page 1 of II.
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SMARTER, t SVARNN I (115TWAR OVA'�8:
Waco of 018auae Sauomnr e„s,
Ki fBen W.U4 iivek it roir'ta's, CA 51'06 OAK
Vtarn n9 51&:244 qVI )BRU 15'.V 11211 Fax- 5152.W `i X93-1
YtYY'iRffidt+:XrffeBEN}4 A.ggv
Ceirtified AIIIIURtrNratrtf Of IDrivUing Shiticard
Xnaquhy Dates
9/18/2014
DL/ID #:
673AJO477 (IA)
Customer #:
6U68081
INasre.
Ibrahim, Amin Mohamed
Ciasm
D
ID Statausr
None
Adam
Addressu
141 33RD AVE SW APT 28
Audit to
8456005
DL Status-
VAL
Issue Date:
09/18/2014
CDL Status
CNfy/Statau
CED IA
Expiration Da
DaiPIDS,
04/05/2018
CDII Cult Stot'�, ar
None
524044642
Endorsements:
.3
CIVIL. Med S bub..
None
Mailing Address:
141 33RD AVE SW APT 28
Restrictions:
NONE
Restriction
None
Date of Birth:
4/5/1968
Supplement
Mailing City/State: CEDAR RAPIDS, IA
Sex:
M
524044642
",.,',"p'IBr” ka;Mn Drdw r,':M imflAvPr:. on Data
&°x uundeu° In 35 55 unlVrh zone)
Namm Ibrahim, Amin Mohamed Adam DL/ID: 673A]0477
JP MIME MWMr
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:
yo.......w 9/18/2014
9 Office of Driver Services
Iowa Department of Transportation
1Nairrn: Ibrahim, Amin Mohamed Adam DL/ID: 673AJ0477
9/18/2014