HomeMy WebLinkAbout14-166Authorization Number 121.._ ) Cete
(Office Use Only)
"Ono
® _
I F 1 A ITY APpLICATIDN FDR T u DTD ED PEDICAR VEHICLE DRIVER
(Police Department roview must be made
410 East Washington Street between 8 a.m. to 3 p.m., Monday—Friday.)
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(3 19) 356-5497 FAX
First Middle Last
1. Name .-- �-ahzzi. q------..__-T"�____
2. failing Addres,%„
3. Telephone: Flla me, -." - Other:
4. Prior, experience in transportation of passengers -------------------
5.
______—___________
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? , JZ2_
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Have you been convicted of any traffic offenses in the last five years?
Where
Rim
When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? A Ar-)
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Wh
ere
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
derWbr4drivbsdg 03/2014
hereby certify that I �h,,��ve issued to me by the Iowa Department of "Transportation a valid Chautteurs license number
a r , Qn rI I-ze B . I understand that if I falsely answer any questions in this application, that this
ti�
p licati � may be denied. I un erstad nd 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 front
of a Notary Public)
9Applicantay Date ,.,...
Signature of� � a ����a � d
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 )
Subscribed and sworn to before me by e ee2m g 'm4 __k Ar9a an r e( On this t °°' -1-1,day of
I 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).
a
_, / ✓
Signatilre of P'olicethiet, 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.
Signature of City Clerk or designee
Date _—
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 %" (width) and 5 %11
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
ae,RRacidrWbadgeapp2014.doc 03/2014
u Aug.,,12. 2014 2:35PM CDiv of Crim nal Investigation ,Na,1163 P. 1/1
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To; Iowa Dlvlalan of Crhalnal Nvutlgatfon
Suppart OperatlongHuroau, l"Floor
115 m 71h 8traat
Des MolYtes,Towa 60319
(616) 7754066
(416) 725 6oeo gay
DCI Account Number.
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IowaCrihtittalllisToryRecofdattached, l)ff ................. .. .. ..... ..... _............
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Cortn1Iled Abstract of, IDrivilirug Rewird
Inquiry Date:
8/6/2014
DL/ID #:
684A77013 (IA)
Name;
Mohamed,
Classes
D
Gamerelanbia Ismail
Addresses
2608 BARTELT RD APT
Audit #:
7189403
2D
Issue Date.
07/31/2013
City/stat®:
IOWA CITY, IA
Expiration
01/01/2018
522462730
Date:
Endorsements: 3
Mailing Addre :
2608 BARTELT RD APT
Restrictions:
NONE
2D
Date of Birth:
1/1/1957
Mailing City/state; IOWA CITY, IA
sex°
M
522462730
CftaUon Daze Comeire„ krol [We
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r171 FrMrn,: t �1
to Ylil r9lld
UZZEEZZECUM
1011„ status. VAL
CDL status. None
CDL Cert None
status:
CDL Med None
Status:
Restriction None
Supplement:
of Way
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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:
8/6/2014
Office of Driver Services
Iowa Department of Transportation
Name: Mohamed, Gamerelanbia Ismail DL/ID: 684A]7013