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Home My WebLink About12-165r CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX Authorization Number \--)- (Office a(Office Use Only) APPLICATION FOR TAXI DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.) First ( Middle Last 1. Name 1�1ng1 t 2. Mailing Address l 1 J <% 4 Y �A 5 2-? u 0 3. Telephone: Home 3 I g 4 7 1 - X Other: 4. Prior experience in transportation of passengers: 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? no Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? A—\T- Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? v%,� Tvpe 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) clerkAesidrivbadg 06/2012 \L -- L- /E C -2\°Y I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license humer 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) Signature of Applicant° Date � / I ° STATE OF IOWA ) COUNTY OF JOHNSON ) bscribed and sworn to before me On this �� day of est Ek 1��J)o�aa o Nsta�Pu lic in and for the tate of owa -713 � k- ***#***#**********************************ii***i***********i*#**k***************************************i***i**ii*i****i*****i*i*******i*iiii#*# 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). Signat e o Poli ief or designee Signature of City Clerk o> d signeee J--1 —/Z Date 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. Office Use Only Approved application DCI report State certified driving record Website update cleiWlaridnWb dg.W2010.d. 0612012 J Iowa Department of Transportation Office of Driver Services (Toil Free) IM -532-1121 PO Box 9204, Des Moines, IA 50306-9254 515-244-9124 FAX: 515-239-1837 Certified Abstract of Driving Record Inquiry Date: 8/3/2012 DL/ID #: 144AC2108 (IA) Customer #: 5262644 Name: Saeed, Khalid Azharl Class: D ID Status: None 10/01/2010 Mohamed S92 :Speed 56 IA Address: 36 ANISTON ST Audit #: 5591124 DL Status: VAL Issue Date: 10/25/2011 CDL Status: None City/State: IOWA CITY, IA 522402216 Expiration Date: 08/17/2012 CDL Cert Status: None Endorsements: 3 CDL Med Status: None Mailing Address: 36 ANISTON ST Restrictions: NONE Restriction None Date of Birth: 8/17/1983 Supplement: Mailing City/State: IOWA CITY, IA 522402216 Sex: M History Information .:;:victions Citation Date Conviction Date ACD Explanation County 7UR 10/03/2008 12/09/2008 S92 :Speed 52 1A 10/01/2010 10/25/2010 S92 :Speed 56 IA -08/26/2011 09/19/2011 S93 .Speed 52 IA Name: Saeed, Khalid Azhari Mohamed DL/ID: 144AC2108 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: : """•.. �%/# 8/3/2012 ' IOWA '. YPX D. 0. T. -'A¢ tc4m-alc: "••"' . Of Office of Driver Services Iowa Department of Transportation Name: Saeed, Khalid Azhari Mohamed DL/ID: 144AC2108 Aug. 9. 2012 4:20PM Aug. `3. 2012 12:35PM Div of Criminal Investigation City Clerk - City of Iowa City STATE OF IOWA Criminal lH(istoirY )RecOrd Check Request Form To: Towa DiVISIel1 of Criminal Inveslllation Support oparations Bureau, 111 Floor 215 x 711 Street Des Moines,Xowa 50319 (515)725.6066 (515)725-6080 Fax CQKI- aid requesting an aeec'�' Record Check on: Y"�\d. L \ S. No.8240 P. 28/30 No.2669 P. 2 DCTAccolsntNulnbcr: 40o0� -r— Qf applicablo) From: CITYOFIOWACITY CITY Cl ERKI S OIrI+ICF 410 E.WASMUr-TO1 SSTWQIT IOWA. CITY IOWA. 52240 Phone: 319356504 Fax: 319-356.5497 I 6 O ��\-I L5Mal421e �1�emale 2'29 / 15 Walvet-xyErorntrrltom Without a sigued waiver from the subject of the reques t, a complete c1'Iminal history record may be reloosable, pet• Code of Iowa, Chapter 692.21 For comnleto criminal lalsfory record Iliformaflon, as allowod by law, always obtain a waver signature &On' the subloct of the request. WatverRelease:ii� hellloptmitaoconordic2methatu11 matninged6ythoDCltall0%aodill(nalshlstojy allowcdcor by ch8ekw7thIllsPlvlsion010iminal lnvoatlgation(DCQ.MY ry Wrt�Vet' Io yaa Criminal ffistor Record Check Results As of 0 '�-�� , a seal:ch of tho pzovided name and date of birth revealed! 1-01 No Iowa Criminal History Record found with DCI Towa Criminal History Rccold attached, DCI DCT initials^,k 0cluasonly) _ L -'7 N G. jy I"I '`7 tJ,"7 I rtl a' "i v L:7;3 -_ co c— k