HomeMy WebLinkAbout12-169i tl�®1��
CITY OF IOWA CITY
410 East Washington Street
Iowa Cil Iowa 52240-182
319)356-504 Weoc 6
(319) 356-5497 FAX
1. Name
Authorization Number y a — 1 (0 )
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
Last
A44mE0
2. Mailing Address I S c{E5 A ' tawti - IA - ti 21-4�S
3. Telephone: Home 26 } - lee?. - 20 )G Other: nKP
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? N O
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? /`f G
Type of offense Where When
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years? Al G
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)
I,_)67
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND ST TF r caT1F1Fn
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)
cletlNe dnvb g 09/2010
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
h t3 I A (s U 5 22 . 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 , l _S_ l Date S- r `�_ — 4Al2
**#**1RR1f f 1HRRYHHH#Hi4#H4H4FR#**t#H1fYHMHHf4YY#YH#H##+#HHi##HHi4HHHHi44*4#HH#i44+#44+##4###t;*Ir41iHH**HH**1fe#f1HRtf
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by '0 SA.nA-4*,y7rA On this /15 day of
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).
?194natur6 of Police Chief or designee
Z?" "Ir I'.." /l . &��
Signalwe of City Clerk or designee
If -/7-/z
Date
�- _20 - /..7
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.
*RRHf1RYHffHYHk##H#*t+it#tk*Ht#f iH11f1RfffflfHHffHH1f f kYYHYHHY##H#Hi#HH44tiit#tHie*ktHHHttHH1HHH.HHHHHHH#Hii##
Office Use Only
Approved application
DCI report
State certified driving record
Website update
dMu<azidd badgeappz 100 09/2010
Aug. 9. 2012 4:17PM Div of Criminal Investigation No.8240 P. 3/30
Aug. 6. 2012 8:160 City Clerk - City of Iowa City
No..2613 P. I//
STATE OV g®'6i6)'A
Criminal History Record Check
Request Form
To; Iowa Division of Celminallnvcstlgatton
Support Operations Bureau, 1"'Floor
215 E. 7u` S31veet
I)cs Moines, Iowa 50319
(516)725-6066
(535) 7256080 ,Fog
ACLAcoountNuma -Fbar: (irnppH Dl
Thom: C(TY OF IOWA CITY
CITY CI FRK'9 OFFICE
430 E. WASUiNGT0NSTRRkYZT
IOWA CrTY IOWA 52240
pboue; 319356-5041
gaxt 319-354-5497
Date of Birth (manda(o
GenrieN mondelnrj SoclaISeeurl Number(rewmmwfld
I9 �-0
2- /G#0 Male OFenaale
z1g81�9
WaYVerYlnfortn ;-' Without
signed
ged WhIcr &Om O omhlet criminal h sfotyrecordi1dormation, as Allowed bylaw. alwayst
bereleasable,p Cod+69.2.e..,,..,Io
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rd
Wadyer Relerrse.tcr mtnalhslorydal� wnumingmothatlemalnla ned DYth�DCtn y'01A, to conduct tOVM D released as m(oaedb law.cecwhh lho Division ofCrlminal
)nresagn4vn(DQ. Any
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As a 0 ' search of the provided name and date of birth revealed.
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N() Iowa Ctlminal Wstoty Record found With ACI
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[� Iowa Criminal111stoxy Record attached, DCI #��
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Iowa Department of Transportation
Office of Driver Services (Toll Free) 800-532-1121
PO Box 9204, Des Moines, IA 50306-9204 515-244-9124
o FAX: 515-239-1837
Inquiry Date: 8/15/2012
Name: Ahmed, Osama Mustafa
Address: 1545 ABER AVE APT 8
City/State: IOWA CITY, IA 522464707
Mailing Address: 1545 ABER AVE APT 8
Mailing City/State: IOWA CITY, IA 522464707
Certified Abstract of Driving Record
DL/ID #:
551AGO523 (IA)
Class:
D
Audit #:
5894946
Issue Date:
03/31/2012
Expiration Date:
05/01/2016
Endorsements:
3
Restrictions:
NONE
Date of Birth:
5/1/1972
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Ahmed, Osama Mustafa DL/ID: 551AGO523
Customer #:
5878593
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, 1, 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, 1 have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date:
tib. ......... 1,
8/15/20122
IOWA
', �F OflIVER -
Office of Driver Services
Iowa Department of Transportation
Name: Ahmed, Osama Mustafa DL/ID: 551AGO523
IOW
A
USA
IA
jip �t II --AMA MUSTAFA ;
1545
r' AS
cnEoRnGA
VE APT!
IOWACI2I
CE 5AA5246 j
Al "ss
08115no1z0523 9/1tl
Class D Exp 04
/2012Rostle
NONE Scx M
nal s.
DOS
0S�01�197 c Eyes OAK
OO 76205/01/1972
60