HomeMy WebLinkAbout12-136r Authorization Number la - i36
F = 1 (Office Use Only)
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APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
410 East Washington Street between 8 a.m. to 3 p.m., Monday — Friday.)
Iowa City, Iowa 52240-1826
(319) 3S6-5040
(319) 356-5497 FAX
First Middle Last
1. Name N1 0 V1a nn D 6�;� S Ma , l a o rt
2. Mailing Address 2 2 3 1 c 6 T} P g t o/ A'� k 7_ C.
3. Telephone: Home Other: S
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? ,J0
Tvpe 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? A) 0
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years?
Tvpe of offense Where When
`1-i-la �J.r.sa,. CoktL� S�oee�
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? /V U
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)
clerk4 idnmadg �A
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
/1 4 3 S 7 / . I 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) �J t
Signature of Applicant / (����\�\ �V a Date 2Z 7 2
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STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me b 1Yl e L o .n i#/ �Gc /n cr� On this o[ 3 day of
��<< Joh ! SONDRAEFORT
z Commission Number 159781
My commission r 1597
0 pires
3/ 7 / oath R 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).
Date
7 -a3 - i#.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
d�ddVeadgeaW2010 09/2D.tp
Ub��o IZ
.�Jul.20.
2012
1:44PM
Div
of Criminal Investigation
No -4813
N'V. -J)
P. 1
F.
:der(,n
Social Security Number (retommendea
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STATE OF IOWA
Criminal flistory Record Check
5
Request
To: Iowa D1'a19lon of Criminal Investlgation
Support Operations 13ureau, l`r Floor
2.15 D1. 714 Street
Das Moines, Iowa 50319
(515)125-6066
(3X5) 725-6060 I'ax
�4 )C'.
Z am requesting as Iowa Criminal Histo v Record Check on:
I)CI Account Number: 400 �D_ --F
(ifapplicoble)
):rom: CITY61 IOWA CITY
C1T cCL1L)Rx s oF0?1C1;
410 E. WASI1 NGTON STRVET
IOWA CITY IOWA 52240
Phone: 319-356-5041
Pax: 319356-5497
Last Name (fran(doo
Mrst Name nm,damrl
MiddleNamte (recommended)
0�10�Date
ofBirthhp menda(oty)omaaloy)
:der(,n
Social Security Number (retommendea
6t /0
�1Nlale t�iOlnae
57753 —�2�g
WalveY.Inf0i fnaii0N: Witliout a signed wAii ei, l •om the subj eet of tha request, a cohip lefe et lmfnal lits(ory recm•d may n of
be reloasable, per Code oflowa, Chapter 692.2, Z~or com lete erlmfnal lristoryreoord Informatio)), as allowed bylatp, always
Wtliver-Reielare: Ilmrebyglvo pertnfarian Cot the above rtluetllogoIficlal to conduct as Iowa efhninl hhloryrecord check w1111 rhe Dlvfsfon orCominal
ravesligadon (M). Any crfminal hfilory data concemingmp that fs maintained by tho DC1 may to releaicd es allowed bylaw.
WalverSignafure:
'(a
Iowa Criminal Yfistory Record Check Results (DCrusa onfy)
As of 7o' 2(j / EL=erch of thc provided name and date of birthrovealed:
No Iowa Criminal History Record found with DCT
Iowa Criminal History Rcoord affached, DCI 0
Received Time7•Jul, I - Q012 2:04PM No.
C iowa Department of Transportation
AO Office of Driver Services (Toll Free) 600-532-1121
PO Box 9204, Des Moines, IA 5030E-9209 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
7/6/2012
DL/ID #:
604AH3571 (IA)
Customer #:
5910902
Name:
Talaat, Mohamed I
Class:
D
ID Status:
None
Address:
6816 COLLEGE PARK CT Audit #:
6043571
DL Status:
VAL
SW APT 7
Issue Date:
06/12/2012
CDL Status:
None
City/State:
CEDAR RAPIDS, IA
Expiration
01/01/2017
CDL Cert
None
524047516
Date:
Status:.
Endorsements: 2
CDL Med
None
Status:
Mailing Address:
6816 COLLEGE PARK CT Restrictions:
Corrective Lenses
Restriction
None
SW APT 7
Date of Birth:
1/1/1982
Supplement:
Mailing City/State:
CEDAR RAPIDS, IA
Sex:
M
524047516
History Information
CLEAR,DRIVING RECORD
Name: Talaat, Mohamed I DL/ID: 604AH3571
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:
Name: Talaat, Mohamed I DL/ID: 604AH3571
7/6/2012
L�
Office of Driver Services
Iowa Department of Transportation