HomeMy WebLinkAbout12-094i r �
CITY OF IOWA CITY
410 East Washington Street
Iowa City, -Iowa 52240-1826
33 3
(319) 356-5497 FAX
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
lI-cl+
(Office Use Only)
Irst �,o Middle Last
1. Name F LA I i ��12 - .4r14 v14 P
2. Mailing Address 112 c & V]
3. Telephone: Home 31 q — < I — ?� 3 � o Other:
4. Prior experience in transportation of passengers: a
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 been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?Ifl_
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? 4/
Type of offense Where When
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? r 0";2
Tvoe 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)
deR taxidrivbadg 09/2010
I herebycgrtify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
1A r 9 5: 1 :7 1 understand that if I falsely answer any questions in this application, that tft
application i a ion may be-derlie4l. 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_ C vn+ j. J f- , N e . A Date ,n1,i1T_n 1 2
STATE OF IOWA )
COUNTY OF JOHNSON ) r�"" -- J� 22
,�pscribed and sworn t9� before me by ,C�fli;t�l El DI?lQi1�� On this J 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).
S��/
ignatu of Police Chief or designee /
SignAture of City Clerk or designee
,_-)' 3 / Z
Date
J5- 1 ,
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
de".,ddmb d�p=o da 0912010
Iowa Department of Transportation
Office of Driver Services {Toll Free) WU-532-4121
PO Box 9204, Des Mmes IA 50306 -9204 515-244-1837
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
4/4/2012
DL/ID #:
379AE8597 (IA)
Name:
Ahmed, Emad EI Dine Balrm
Class:
D
Address:
342 FINKBINE LN APT 9
Audit #:
3798718
Restriction
None
Issue Date:
10/17/2009
City/State:
IOWA CITY, IA 522461714
Expiration Date:
06/26/2014
Endorsements:
3
Mailing Address:
342 FINKBINE LN APT 9
Restrictions:
NONE
Date of Birth:
6/26/1974
Mailing City/State: IOWA CITY, IA 522461714 Sex: M
History Information
Convictions
Customer #:
5558422
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Citation Date Conviction Date ACD Explanation County 3UR
01/09/2011
0210 9/2011 '592 Speed ;52 IA
Name: Ahmed, Emad EI Dine Balrm DL/ID: 379AE8597
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:
- •. ."
4/4/2012
IOWA
10.
t ....I.. S
Office of Driver Services
.��81110
Iowa Department of Transportation
Name: Ahmed, Emad EI Dine Balrm DL/ID: 379AE8597
Apr,10.
20121111:13AM�
Div
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