HomeMy WebLinkAbout12-074CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 3S6-5040
(319) 356-5497 FAX
First
1. Name
2. Mailing Address
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
Middle
Last
i,2-yq
(Office Use Only)
3. Telephone: Home Other: 9 — 5?
4. Prior experience in transportation of passengers: j d COL
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? / ✓�%
Type of offense Where When
6. Have you beeg 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? / j
Type of offense Where When
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? /l/,,
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 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)
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I hereby certify that 1 have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
'D 2� A C n i 7 � . 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)P3/
Signature of Applicant —' Date 1 �0 Z
STATE OF IOWA )
COUNTY OF JOHNSON )
S� b� ribed a d sworn to before me by _
s!u . KELLIE K.
c.LOn this day of
'Uoer2zt819 otary Public in and for the State of Iowa
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).
!f'
ignatur of Police Chief or designee
SignSign u lerk 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.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
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Iowa Department of Transportation
Office of Driver Services (Toll Free) OM -532-1121
PO Box 9204, Des Moines, IA 50306-9204 515-244-9124
UP
4
FAX -.515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 3/13/2012 DL/ID #: 523AG2892 (IA) Customer #: 5833128
Name: Bashir, Tahir Mohamed Class: D ID Status: None
History Information
DL Status: VAL
CDL Status: None
CDL Cert
None
Status:
CDL Med
None
Status:
Restriction
Ahmed
Supplement:
Iowa Department of Transportation
Address:
2422 BARTELT RD APT
Audit #:
5232892
213
Issue Date:
05/18/2011
City/State:
IOWA CITY, IA
Expiration
01/07/2016
522462708
Date:
Endorsements:
3
Mailing Address:
2422 BARTELT RD APT
Restrictions:
Corrective Lenses
213
Date of Birth:
1/7/1973
Mailing City/State: IOWA CITY, IA
Sex:
M
522462708
History Information
DL Status: VAL
CDL Status: None
CDL Cert
None
Status:
CDL Med
None
Status:
Restriction
None
Supplement:
Iowa Department of Transportation
Convictions
Citation Date Conviction Date ACD Explanation _ County _AIR _
11/20/2011 12/09/2011 M14 Fail to Obey Traffic Sign/Signal 52 IIA
Name: Bashir, Tahir Mohamed Ahmed DL/ID: 523AG2892
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:
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3/13/2012
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...........
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Office of Driver Services
Iowa Department of Transportation
Name: Bashir, Tahir Mohamed Ahmed DL/ID: 523AG2892
Y Mar. 6. 20121 2:20PMI
Div of Criminal Investigation
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Received Time e, 28. 2012 8:59AM No, 5620