HomeMy WebLinkAbout12-109� r 1
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CITY OF IOWA CITY
410 East Washington Street
Iowa Cit I Na J
g
(319) 356-5497 FAX
First
1. Name r�
2. Mailing Address
Authorization Number is — /0�
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
Middle
Last
3. Telephone: Home 1 3 I9-) 13 h 3 9 5t -SL Other:
4. Prior experience in transportation of passengers: /Uy
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /` f e)
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? 10 p
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? /JC9
Type of offense Where When
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? bin
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)
derWlaxidnvbadg 09/2010
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
Req ZZ . I understand that if I falsely answer any questions in this application, that this
application may be denied. I understand that if 1 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 _1/ Vi Date
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by =6fak; R. 2bL; , On this 611/V day of
RAE
i y�CommisomSONONumberFORT 759791 Sn.-br.. rbc,lj
May��m'n Notary Public 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).
Signa re of Police Chiqakr designee
t • ,
Signature of City Clerk or designee
-s=ia
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
derPAexlativ Wq..,2010. 09/2010
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1027 DIANA ST
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t IOWA CITY, IA -52240
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CA
Iowa Department of Transportation
Office of Driver Services (Toll Free) WO -532-1121
PO Box 9204, Des Moines, IR 50305-92134 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Data:
5/24/2012
DL/ID #:
809ZZ1230 (IA)
Customer #:
2407754
Name:
Ibrahim, Ibrahim All
Class:
D
ID Status:
None
Address:
1027 DIANA ST
Audit #:
5996624
DL Status:
VAL
Issue Date:
05/22/2012
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
01/01/2017
CDL Cert
None
522404673
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
1027 DIANA ST
Restrictions:
Corrective Lenses
Restriction
None
Date of Birth:
1/1/1958
Supplement:
Mailing City/State: IOWA CITY, IA
Sex:
M
522404673
History Information
Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case NumberIUR
.___ _.__ .._.__.._ .................__ _........ __...... . _�......_.. _. __ _......_.___ r._-._. __..... _..,
09/10/2007 1394308 JA i
Name: Ibrahim, Ibrahim All DL/ID: 809ZZ1230
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:
-• ��'/ ,
5/24/2012
IOWA •'•?°o,
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Iowa Department of Transportation
Name: Ibrahim, Ibrahim All DL/ID: 809ZZ1230
5/24/2012
,J u n. 1. 2012 1: 03 PMi
May. L4. LU I L L; USrIY
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Received -Ti meeMay.24. 2012 2;09PM No.6911