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Home My WebLink About12-081rlll®i�Il CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX Authorization Number 10Q — APPLICATION FOR TAXI DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.) First Middle 1. Name .�, I tf Z &'ALast f L 2. Mailing Address Cft ,CSGS i2 3. Telephone: Home Other: 4. Prior experience in transportation of passengers: 21 /fa YS 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When (Office Use Only) 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? ^( .-1 Type of Offense Where 7. Have you been convicted of any traffic offenses in the last five years? Type of offense ;JdY)e_ Where When When 8. Has your drivers 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 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) derMaxidrivbadg 09/2010 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license num r s 2 46 (O 162 . I understand that if I falsely answer any questions in this application, that thi 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 Tide 5, Chapter 2, of the City Code. (Needs to be signed in front of a Notary Public) q c, 3c, I ( 2 Signature of Applicant Date rxrayray.a.++........�-n,,..a.a..a....a...eoer..+.e.+weero-+me.....r.k.w+�r.a..a.....r...ri...a.....a.r..m.....aa..w.m.w...e.+s�.e.em++. STATE OF IOWA ) COUNTY OF JOHNSON ) Sabscn'�nd� orp�to before me by 14-n I On this -30 � 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). J�E�%�r� 33D -/Z Signature of Police Chief or designee Date Sig re of City Clerk or designee 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 clerMa dnmadgea,201 o.d« 09/2010 Iowa Department of Transportation Office of Driver Services (Toll Free) 800-532-1121 PO Box 9204, Des Moines, IA 50306-9204 515-244-9124 1*0 FAX: 515-239-1837 Certified Abstract of Driving Record Inquiry Date: 1/10/2012 DL/ID #: 375AE6102 (IA) Name: Elneil, Siham Class: D Address: 915 BOSTON WAY APT 2 Audit #: 5653235 Restriction None Issue Date: 11/29/2011 City/State: CORALVILLE, IA 522411270 Expiration Date: 11/29/2013 08/04/2011 iS92 _Speed _ Endorsements: 3 Mailing Address: 915 BOSTON WAY APT 2 Restrictions: Corrective Lenses 'IA j Date of Birth: 12/31/1959 Mailing City/State: CORALVILLE, IA 522411270 Sex: F History Information Convictions Customer #: 5553741 ID Status: None DL Status: VAL CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: 03/29/2011(M14 Citation Date Conviction Date ACD Explanation County ]UR ...._, -_.........e..,...__.._._._..... 04/27/2010 .�._.,....__..._.._...__._._.._ 05/24/2010 ..06 .. ..._� ._ .......m.�,..,..... _.._�. =N01 Fall to Yield Right of Way f._.., ....... .... ... .._ .. 'S9� »--.._,.-�,.....-.-,—. _ _ 57 .. .. 52 .._._, ..__._� _IA 05/14/2010 06/21/2010 2 Speed � _IA 02/20/2011 03/29/2011(M14 Fail to Ohey Traffic Slgn/Signal X52 SIA 05/30/2011 08/04/2011 iS92 _Speed _ 152 - IIA 06/06/2011 110/07(2011 .E55 :Driving Without Headlamps or With Park Lamps .52 'IA j Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number IUR 04/27/2010 1571208 IA Name: Elneil, Siham DL/ID: 375AE6102 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: •'�'/�"p 1/10/2012 IOWA E =4m, alcvw� D. 0. T..:s f••••••'$�E� Office of Driver Services I„IT,S--- Iowa Department of Transportation Name: Elnell, Siham DL/ID: 375AE6102 State of Iowa Division of Criminal Investigation 215E7`hSt Des Moines IA 50319 Ph. 515-725-6066 Fax 515-725-6080 Iowa Criminal History Record Check Walls -In Request Your name ,rham First Name Primer Nombre (mandatory) Addresst Ea1 -n -e l L City/State/Zip Ccyrvl_ i Phone# 3/ _ 501 , S Requestina an Iowa criminal history record check on: Fill in all shaded areas. Last Name Apellido (mandatory) First Name Primer Nombre (mandatory) Middle Name Segundo Nombre (recommended) Ea1 -n -e l L °'1n v`.. Date of Birth Fecha Nacimiento (mandatory) Gender Genero (mandatory) Social Security Number (recommended) 14% g t j 1r, 6-9 []Male ❑.F male Waiver Signature Firma (If the request is on yourself, please sign. If the request is on someone else, write N/A.) DCI USE ONLY Results As of /— a name and date of birth check revealed: PNo record found ❑Record attached, DCI # DCI initials Receipt Number of requests x $15.00 per last name = Total amount $ i S - 0 U Method of payment: Wcash ❑money order ❑check # []MasterCard or Visa Cardholder's name Last 4 digits of MC or Visa DCI initials Credit Card Number # Exp. Date