HomeMy WebLinkAbout12-061I r
13
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240!-1826_/
7
(319) 356-5497 FAX
Authorization Number /a - & /
(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 Last
1. Name Ctl.n C �ame\c,a n 'A k'�
2. Mailing Address Z t "1,� � 1LS a �e N It rt --Tlk `j It
3. Telephone: Home Other:
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? ��) �I 1)
Type of offense Where When
6. Have you bN q convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? e-
TVDe of off nse Where When
SP E P w a �L:- I
s p Po
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
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)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND SIAIELEELTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR CE CHIEF REVIE
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)
derlNaxidrivbetlg'
09/2010
I hereby certify that I have issued Yo me by the Iowa Department of Transportation a valid Chauffeur's license number
`��
r� 6 A Z) ::`a %o R . I understand that if I falsely answer any questions in this application, that this
application may a deni d�erstand 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)
Signature of Applicant ' f Date
STATE OF IOWA )
COUNTY OF JOHNSON )
scnbedand sworn to before me by Svrn',r �,sgR„e,atir,<< On this day of
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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).
SignatuYe of Police t1fiefcesignee
SiEinatu're of City Clerk or designee
Date
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.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
derWiexbNbatlgeapp2010.d 09/2010
Fe6:24. 2012 2:21PM Div of Criminal Investigation hNo,�5353 PP. �1
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3eceived Time Feb, 21. 2012 8:36AM No, 9689
' (nCl aro only)
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Office of Driver Seivices
• Box 9294, r.Moines,
Inquiry Date: 2/28/2012
Name: Ali, Samir Isameldein
Address: 2427 BARTELT RD APT 2B
City/State: IOWA CITY, IA 522462710
Mailing Address: 2427 BARTELT RD APT 2B
Mailing City/State: IOWA CITY, IA 522462710
Convictions
of Transportation
(Tall Free) OW -532-1121
515-244-9124
FAX: 515-239-14337
Certified Abstract of Driving Record
DL/ID #: 266AD7808 (IA)
Class: D
Audit #: 4018270
Issue Date: 01/14/2010
Expiration Date: 11/03/2013
Endorsements: 3
Restrictions: NONE
Date of Birth: 11/3/1985
Sex: M
History Information
Customer #:
5429309
ID Status:
None
OL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
_
FSp_eed
Citation Date
Conviction Date
ACD
Explanation
County
3UR
01/09/2009
r 02/06/2009
rS92
Speed _ ..
52
dA j
__e_,.. ,. .....m . .. ..............,..�
08/2_6/2009
_
-`10/16/2_009
.�
592_
_
FSp_eed
52
T_.
',IA I
09/09/2009
"11/25/2009.n.._........._.m................w.....r..._..—.,592
!Speed
52�=1A���
Name: All, Samir Isameldein DL/ID: 266AD7808
Pursuant to Iowa Code §321.10, I, Kim Snook, Director of Office of Driver Services, 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:
;i ...... b/°V
IOWA N
D. 0. T.; i
r
2/28/2012
f ��5
Office of Driver Services
Iowa Department of Transportation
Name: All, Samir Isameldein DL/ID: 266AD7808