HomeMy WebLinkAbout12-050�r
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-SO40
(319) 356-5497 FAX
Authorization Number /3—so
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
First Middle
1. Name Ab Act 1(:-Z i ('rti`2
2. Mailing Address e✓C'rl /11 -et et S'frcc+, Ccwc—f f /v`1
3. Telephone: Home Other: 3 t
4. Prior experience in transportation of passengers: I . ;' t � �) -kf I 1 o w Cc p
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /,/C"
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? ,vn
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? ✓r
Type of offense Where When
P, e. d' /c v' -t 5 - 2, 10
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 7y C'
TVDe 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 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) The re-
port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli-
cation.
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
deNtn iaivbadg 09/2010
1573 Cc G V91
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
I—/ s : C 4 99 . I understand that if I falsely answer any questions in this application, that this
application 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 front
of a Notary Public) /'
t
Signature of Applicant �Date
,44,4.44#4#4«#«««**«Yi#«««444#«*4k.44.#4.4kY«.#44Y4«..,f4#YY,Y.4.,.N44,Y.,.4YY44..44»4YY14444444Y4Y4..,.4YYY4,...44YYf4,Y.4..444M.4,N44444..
STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by -A4ejmgd, 0MI, Mm, tgzi� . On this .13 day of
SONDRAEFORT
i4#Y#Y44Y4Y44Y####*k****hk#*#k4##Y4#YY###44Y4444Y4444Y4YRRRY4RM4YRRR4R#RMY4}kkk*RkR4kRM4R#Rk#4R4RRkR#R}#R}#*kR*RRRRR***#*MkkRkkRkkkkkRRMRRR**Yk
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).
gS nature of Police Chief or designee /
Sigs retu�Clerk or designee
2—z3 �Z
Date
�-a3 -ice
Date
After Police Chief and City Clerk have approved authorized taxi driver names will be placed on the city website at icgov.org.
Taxi cab businesses are required to provide Driver Identification cards.
H4.444444*#Y44««4fe«4.«4..Y4Y44444.#44Y444#MR4«44««4*4«4«H«N#««4«4YY«'4*«««,4««144««44##«1rt«««44k4«4Y'4444444fe«44NYHHY.44444f MYf4144#4#4f#44
Office Use Only
Approved application
DCI report
State certified driving record
Website update
CarWl do b geapp2010.d« 09/2010
Iowa Department ofTransportat an
Officea Driver Services (Toll Free) 8011-532-1121
PQ Box; 9204, Des Milnes, IA W31)(11204 515-244-9924
FAX: 515-M-1837
Certified Abstract of Driving Record
Inquiry Date:
2/14/2012
DL/ID #:
153CC6499 (IA)
Customer #:
4289037
Name:
Ahamad, Abdalazlz Omer
Class:
D
ID Status:
None
Address:
809 Hughes Street
Audit #:
2431297
DL Status:
VAL
02/14/2010 -
03/05/2010
Issue Date:
08/12/2008
CDL Status:
None
City/State:
Coralvllle, IA 52241
Expiration Date:
01/01/2013
CDL Cert Status:
None
Endorsements:
3
CDL Med Status:
None
Mailing Address:
809 Hughes Street
Restrictions:
Corrective Lenses
Restriction
None
Date of Birth:
1/1/1959
Supplement:
Mailing City/State:
Coralvllle, IA 52241
Sex:
M
History Information
Convictions
Citation Date
Conviction Date
IOWA ?*'
Explanation
County
]UR
09/06/2008
09/25/2008 _
_ACD
;592
W Speed
152_
I_A_
��2010.
Passing School Bus
_
>IA
02/14/2010 -
03/05/2010
592
S eed
E52
?IA j
09/05/2010
:592
ISpeed�f 0.eµ _
152
`IA
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number IUR
._ — -t
(527562 )IA
07/26/2011 640594 IA !
Name: Ahamad, Abdalazlz Omer DL/ID: 153CC6499
`
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of DriverServices, 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:
•••"..... '4
2/14/2012
IOWA ?*'
T.:4-'
c4tv atlg�k
yf ""'•''S
Office of Driver Services
Iowa Department of Transportation
Name: Ahamad, Abdalazlz Omer DL/ID: 153CC6499
FalrlFeb.20. 2012 9 59AMesbaD goof Criminal fnvestigation
S
319-33e-2709No.4646 P..41/5
STATE OF
Criminal ffistory
Record Check
0
t aa
a , a y ,
Tot Iowa Ontsion of Criminal lnvesllgatton
Support Operations bureau, 10 Floor
215)E. 7d' Street
Des Moines, Iowa 50319
(515) 725-6066
(515)725.6060 Fax
I am reauestine an Iowa Criminal Ristory Record Check on,
DCI Account Number: _9967-F
(ifglpbeable)
t+rom: Yellow Cab afIowa City
P.O. Bore 428
Iowa City, LA. 52244
(319) 338-9777
Phonet
Fax; (319)339-7302
LastNaOle (mandatory)
First Name (mandao)
Middle Name (rewmmentkd
Abmme�id
AbdA
v,�
Date of Birth (numdmoy)
Gender (mandatory)
Social Security Number imnun tided
Omsk ❑Female
u � �-4 1
Wdiverinformar oR: Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapier 02.2. For complete criminal history record information, as allowed bylaw, always
obtain a waiver signature from the sub-ent of there gest,
Waiper lfelease: lhctehy give pamission for the above rc4wslingotincial ro conduct an Iowa miminal history re and check with dte Division ofCdtn)n91
lnrosagnlon(oCb• Any ctiminel his+ory dais wnecming me that ismainWocd bythe D1C�l nybemleased asallowed bylaw.
Waiver Signature.
Iowa Criminal History Record Check Results (DCI use only)
As of a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DC1
I •
❑ Iowa Criminal History Record attached, DCI ii
DCI initials
DCI -77 (0,125110)
Received Time Feb, 14, 2012 10:10AM NOW