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HomeMy WebLinkAbout12-1151 Z 1 CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 s} (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.) /��_ -i i 5 (Office Use Only) First Middle La t 1. Name c 2. Mailing Address � � Soa C_g s A 76 C QciGY� �q�l �� 3. Telephone: Home � � —fk' ljt� Other: 4. Prior experience in transportation of passengers: r 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? fJ o 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?Ut— Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years?j n Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 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) GerkXaxiCnvbaCg 09/2010 I hereby ceify tha�haye i sued to me by the Iowa Department of Transportation a valid Chauffeur's license numbgr U �( �{ 1 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 ofAppliSAnt },-� Date f STATE OF IOWA ) COUNTY OF JOHNSON ) ,/�� I,, Su Bribed and swom to before me by I I a ` t On this day of © ? . l<�e,c,'t' KELLIE K. TtITiLE Nota Public in and for the State of Iowa =t ► 4��e"a-ir�i:r:,.,, �Y - •� My c9mtni�*,p. res 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). Signature rofPolChief or designee jei - ign ure of City Clerk or designee ,�� %/Z 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 dew &Mled�2010.a - 0912010 V Jun. 5. 2012! 3:46PM Div of Criminal Investigation u l u` • L J. L V I d L, VU I III V I I r V I e I a V I I. p U I I V n a V I t y J STATE OF IOWA Criminal History Record Check 0 Request Form To: lova MV)s(on of CriminalIrlvesilgatlon Support Operations Bureau, 1" Nloor 215r, 71h Street Des Molilw, Iowa 50319 (515)725-6066 (515)129,6080 X+ax I ain requesting an Iowa Critninal RistorvRecord Check on: INu; 78 t)1 1P. Al/3 DClAccountNuinber, �{ aaa --P (iroppl(coblc) Frame CXTY OYr YOWA CITY CXTY CL' ERir'S OFFICE 41012, WASWNGTON STREET XOWA CITY IOWA 52240 Phone: 319-356-5041 Fax; 319-356-5497 Last Nalue (riandnimy) First Name (mondaro Middle Name (recommended) � C,ka, 'n Aate of/Birth (himdaloly) Getld�efr (mal aero y) Social Security Number (recommended �� J �� / 1 �� WNXaIe ❑Female ��� � " -C4 Waiver.ltrjoruration: Without a slgued waiver from the, subject of.'the request, a complete erlmtnal history record may not be reloasable, per Code of lawn, Chapter 692.2. For coni lee criminal history record Information, as allowed by law, always obtain a waiver sign ture from (ha subject of (]le request. WMBvef'. tele[IMIherebygivepermissionfor16caboverequestingofficialtowadedalIowacriminalhhtoryrecordcheckwhhdmDivisionorcdmtnsl Investigation(Dcb. Any criminal history dalq ronaeming No lhol is mainlaincd bythe DCI mgyborefeasedasallowed bylaw- Waive? Signature: • V - /Iowa Criminal History Check Results (DCI use only) As of a search of the provided name and date of bhth revealed: No Iowa Criminal Mstory Record found with= d Iowa Criminal iiistoryRecord attached, ACI # "' Ml initials - Iv v7 I)C1--77 (08/25/10) Received Time May.29. 2012 2:02PM No.6700 CIowa Department of Transportation Office of Driver Services (Toll Free) WU-532-1121 PO Box 9204, Des Manes, IA 50306-92134 515-244-9124 FAX: 515-239-1637 Inquiry Date: 6/15/2012 Name: Bachar, Mahamadine Address: 265 KIRKWOOD CT SW APT Audit #: 10 City/State: CEDAR RAPIDS, IA Expiration Date: 524048263 Mailing Address: 265 KIRKWOOD CT SW APT 10 Mailing City/State: CEDAR RAPIDS, IA 524048263 Name: Bachar, Mahamadine DL/ID: 499AG1741 Certified Abstract of Driving Record DL/ID #: 499AG1741 (IA) Class: D Audit #: 5814607 Issue Date: 02/22/2012 Expiration Date: 01/01/2017 Endorsements: 3 Restrictions: NONE Date of Birth: 1/1/1982 Sex: M History Information CLEAR DRIVING RECORD Customer #: 5797950 ID Status: None OL Status: VAL CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: 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: ...... IV 6/15/2012 10 WA D. O.T...1 F DBIIIF��S Office of Driver Services Iowa Department of Transportation Name: Bachar, Mahamadine DL/ID: 499AG1741