HomeMy WebLinkAbout12-130� r 1
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
Authorization Number /. — l3 C)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
(Office Use Only)
First Middle Last
1. Name 'yl U k WTf1' M ftf-C
2. Mailing Address au �O 95fr LT -t-Of ''b PD ¢/ % 1) 1 I o w A L' 177 (I A S2 2 Lf 6
3. Telephone: Home 319 tt" I -j 3 4 Other:
4. Prior experience in transportation of passengers:
q es'
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? N D
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? N o
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? N o
Type of offense Where When
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? N D
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) N O
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 certifythat I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
S2 R? LJ R . I understand that if I falsely answer any questions in this application, that this
application maybe 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 rds and documents relating to this application, and I further agree that, if a license
is granted, to comply at all timesth all of he provisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public)
Signature of Applicant Py i Date -1 1 R j (2-
STATE
2
STATE OF IOWA )
COUNTY OF JOHNSON
Su4cribe� and sworn to before me by I u ` (� r �lOL rt7 F� On thisy " day of
KELLIE K. TUTTLE ��� i� /u
Commission Number 221BI9
Notary 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).
-7-1i-la
Date
%` /,? -/,Z
Date
NOT VALID UNTIL Police Chief and City Clerk have approved and authorized taxi driver names 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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Jul. 5. 2012 3:15PM Div of Criminal Investigation
V V .1. L I. LV I L I L. -1,11 111 L I I J V I G I A V I t y V 1 1 V n a V I l y
STATE OF IOWA
Crixiiinal History Record Check
10 RequestPorm
To: Iowa DIvlslon of C"rlmlllal Xnvostigation
Support Operations Bureau, I" river
215 E. 7'h Street
DosMoileaa,IOWa 50319
(515) 725-6066
(515)729.6080 Fax
GX�
T am reanestina an Towa. Criminal 1414oro Record Check oo-
hNo.�2094 JVJPP. rl/1
U.
DCI Account Number;
(iP applicable)
From: CITY OF IOWA CITY
CITY CLERK'S OFFICE
410 E. WASMNGTON STREET
IOWA CITY IOWA 52240
Phone: 319'356-5041
Fax: 319-356-5497
Last Name (mandatory)
First Name (mandatoiy)
Middle Name (recommended)
Date of Birth (mandatary)
GCulder (mandatory)
Social Security Number (recommended
to I 14) /10
EIWrAlo dFemale
G 26 -moi - x'81 PJ
WfatlieilInforillfdfion: 'Without a signed waiver from the subject of Elie request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2. For eo le criminal history record Information, as allowed bylaw, always
oblainawaiver signature from ihesubject ofthe request,
Waiver Release: thereby give pennissionfor iita claltoeoaductonIowa odmlalhistory recordcheck wiUuheDivisloaofCriminal
cdhylhobCimeyborclt4sc4eaalloNcdbylaw.Inveslloallosl(DO). Any criminal bistorydalaconcmin
g
Walvew Slgnnlu► e:
Iowa Criminal History Record Check Results. oo�rea,a„tv)
As of 7 a search of the provided name and date of birth revealed:
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No Iowa Criminal history Record found with DCI
Iowa CrjWnal history Record attached, DCT #
ACI initials
Y�/VT 7M / H /� O
Received Time'Jun, 2 012 12:44PM No. 86
ACIowa Department of Transportation
Office of Driver Services (Toll Free) 8W-532-1121
PO Box 9204, Des Moines, IA 5(13(16-9204 515-244-9124
OFAX: 515-239-1837
Inquiry Date: 7/18/2012
Name: Adarob, Mukhtar Mohamed
Address: 2420 BARTELT RD APT 1D
City/State: IOWA CITY, IA 522462707
Mailing Address: 2420 BARTELT RD APT 1D
Mailing City/State: IOWA CITY, IA 522462707
Certified Abstract of Driving Record
DL/ID #: 527AG8848 (IA)
Class: D
Audit #: 5625033
Issue Date: 11/10/2011
Expiration Date: 10/14/2016
Endorsements: 3
Restrictions: NONE
Date of Birth: 10/14/1969
Sex: M
History Information
CLEAR DRIVING RECORD
Name: Adarob, Mukhtar Mohamed DL/ID: 527AG8848
Customer #:
5836959
ID Status:
None
DL 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:
>."""•7;`/�4�
7/18/2012
D.. 0. O. T.
f
Office Driver
UN�VEH S`=�
of Services
Iowa Department of Transportation
Name: Adarob, Mukhtar Mohamed DL/ID: 527AG8848