HomeMy WebLinkAbout12-177� r
7tIII
�+ EcIr
CITY OF IOWA CITY
410 East Washington Street
Iowa Lity, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
First
1. Name
2. Mailing Address
Authorization Number /a —177
1 q ; k loacC (Office Use Only)
1a
61,FA ak In 641
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
MiddleA�— i 1 S dd G Last ' f �e_
1a.�,r
3. Telephone: Home 3 (a- q3 G _ IgS ► Other:
4. Prior experience in transportation of passengers: A FS
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? ('(_)o
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? -) V
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? yk-
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? lIy
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)
derkA.idrivbadg 06/2012
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
�f Y 08 aO . 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 „✓tai _ Date a c -i 24 It-
STATE
Z
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by "'V4 c a4 z l n; < On this day of
1" r` ks���### SONDRAEFORT �—
�z Commission Number 759791viu.t_ t'C/f�7
My Comv ssion E1" Notary Public in and for the State of Iowa
3/7 JO
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
ay , iC;I-
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
cl.rW idrvbe ,..,,2010.d. 06/2012
• Aug. 17. 2012 9:56AM Div of Criminal Investigation 6No.,9444 PP. 3
1-1. J• Vr/VV� rVV4
-0� blrna> inal.Historcy Record Check
Request ]Form
To: 1owabiv1sion orcriminalynvestigatfort
Support Operatlons Hurenu,1" Moor
215 E. 71H SirOt
bovMpines,Towa 50319
(510) 725,6066
(515)12S-6080 Bax
Iam
�ClAeoowteNumlier: `� °Oa ! .
(ffnpplfdeblc)
)F O)u: CITY OF IONA -TTP
CITY CLTsVs OFFICE
410 R. TJASE1DTGTON GMABT
T017A CITY IOTTA- 52240
Phona; g19-356--5041
vw 319-956-5497
LasCNWago mndntoI h`lrsfiNAMO mandate Middle Name(/ecomme,dcd
f3
oj- / 1.(0 / I q80
�YnRvertr;rornfatlo�; p/(thout n
ba roleASA6I� perCodaol'xa{vA, C.A
nhta4n n mnfvnr clenalova A•nm IW<.
Wralberhefense;
1nV651fgetron COC))- Art
Wnlver
I�Ma1s )� omaTe &35, 69 Sago
t H/ah�e1•lYom f4esu6jecC oftho Yeggesd`I 9 complete aY(t9fna11S(sfoYy record nen}/ )iot
69=. 1761- poM pleeerlmfnalLtsioxyl•coordlnrorinWoh,adnllowodbylAlr,Au./Ays
tbrtho above requulln�offioinf lv wn Ira Y°�vn orlminnlhlslotylcoocd obaok Wlh lhaDNisiovofCnminoi
tmmflploLit istnaintalnodbytfiori moyborofcuodavnllo�vaQbyfAW.
t1.s oi,�l � 1 � Y �, a sear.Ch 0£thc,�rowided name and data of bi>.thsaveeled;
No IWIE( C>;1whial E.WoryRowid foiind with DCT
b .i0'Wa Othf ialHisfoxyRecord auachheed, DOU
bCl;ilaifials f �
DCX -77 (08/25/10)
Received Time Aug, 13. 2012 2:13PM No, 1238
ro�l dao only)
r
ry
u) ,.
.,I
' �'i•I�
V)
C=i
Nom`,
CJ
)Yl t�
s-^
w
Iq
Iowa Department of Transportation
i 0 Office of Driver Services (Toll Free) 800-532-1121
PO Box 9204, Des Moines, IA 50306-9204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
8/21/2012
DL/ID #:
713YY6890 (IA)
Customer #:
2068875
Name:
Hagelamin, Tawfig All
Class:
D
ID Status:
None
Elsiddig
Address:
811 HUGHES ST
Audit #:
6119105
DL Status:
VAL
Issue Date:
07/12/2012
CDL Status:
None
City/State:
CORALVILLE, IA
Expiration
07/16/2017
CDL Cert
None
522412143
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
811 HUGHES ST
Restrictions:
NONE
Restriction
None
Date of Birth:
7/16/1980
Supplement:
Mailing City/State:
CORALVILLE, IA
Sex:
M
522412143
History Information
Convictions
Citation Date Conviction Date ACD Explanation County IUR
12/13/2007 12/27/2007 S92 Speed 52 IA
Name: Hagelamin, Tawfig All Elsiddig DL/ID: 713YY6890
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:
�......... :;v/J�y
8/21/2012
IOWA
D.O.T.'
Office of Driver Services
,i\\...... ,—=
Iowa Department of Transportation
Name: Hagelamin, Tawflg Ali Elsiddig DL/ID: 713YY6890