HomeMy WebLinkAbout12-06777►4 � y�®r�,l
CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa S2240-1826
(319) 356-SO40
(319) 356-5497 FAX
1. Name
2. Mailing Address
3. Telephone:
W
4. Prior experience in transportation of passengers:
Authorization Number I %— to 7
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
Middle
Other:
2
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? _�J 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 /e/ O
years?
Type of Offense
Where
When
7. Have you been convicted of any traffic offenses in the last five years? X le S
Where
When
Iti/13/2-0
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8. Ha your driv rs license or chauffeurs license been
Type of offense
ispended or revoked in the last five years? r��r
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) , "'
�
S'Q�Sav\ CriYh4� /M
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)
Gerk/t xidrivbadg 09/2010
I herby certify t��at I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number`
i F� O `j 23 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)
Signature of Applicant Date
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by S 4w Sa\" ��N\, cAA 6 hlgr— On this (3+ day of
'ublic in and for the State of Iowa —
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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).
/— /2
Signatu o Polj e i r designee Date
3
Signature of City Clerk or designe 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.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
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Receive Time Feb, 24. 2012 4:41PM No. Di
r
CIowa Department -of Transportation
Office of Driver Services (Tall Free) 800-532-1121
PO Box 9204, Des Moines, IA 5030E 9204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
2/28/2012
DL/ID #:
059AA0923 (]A)
Customer #:
1559313
Name:
Omar, Sawsan Khalil
Class:
D
ID Status:
None
Address:
2240 9TH ST
Audit #:
5483219
OL Status:
VAL
_
11/12/2011
._ _ _
112/12/2011
Issue Date:
09/01/2011
CDL Status:
None
City/State:
CORALVILLE, IA
Expiration
01/01/2016
CDL Cert
None
Type
522411567
Date:
ACD Explanation
Status:
JUR
Suspended
j06/20/2007 ,OB/18/2007
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
2240 9TH ST
Restrictions:
NONE
Restriction
None
Date of Birth:
1/1/1972
Supplement:
Mailing City/State:
CORALVILLE, IA
Sex:
F
522411567
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
JUR
D. O. T.:Wi
12/13/2006 _ -- -
1592
_ Speed
_ - - - -- _ -
- 7
IA
0_6/24/2008
07/15/2008
S92_
_Speed
52
IA
_
11/12/2011
._ _ _
112/12/2011
_
;M14
_�
Faii to Obey Traffic S(gn/Signal
_
52
IA
Sanctions
Type
Effective End
ACD Explanation
Occurrence JUR
JUR
Suspended
j06/20/2007 ,OB/18/2007
;S92 ,Serious Violation
IA
IA
Name: Omar, Sawsan Khalil DL/ID: 059AA0923
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:
°""'• :R%'4
2/28/2012
IOWA
D. O. T.:Wi
.::
PF, �A S�J
Office of Driver Services
�% ",.:
Iowa Department of Transportation