HomeMy WebLinkAbout12-185CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
First ,�
1. Name Omer
2. Mailing Address /26; SW,Sher S
3. Telephone: Home 3 19 - k5S- y 2 3'-(
4. Prior experience in transportation of passengers:
Authorization Number j — /U 5
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
Middle MohGmed
Other.
(Office Use Only)
Last LMgssoin
- G5
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
No
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? 1,)e
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense Where When
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? 0
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)
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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 certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
313A E n 14 Z . 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( /r�1�s� ✓I Date gr/ 2 9// Z'
STATE OF IOWA )
COUNTY OF JOHNSON )
S scribed an sword to before me by `� '� r E� s Sa n On this 2—
SO
— day of
LQ.I /
o r,k KELLIE K. TUTTLE
iz ? Commission Number 22181 tary Public in and for the State of Iowa
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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).
-'SignatLA of Police Chief or designee
t
3✓i/jZ1 71/./lif/
Sign re of City Clerk or designee
gj7-�79 i
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
derWtavidnvbadg ,,2010.do 06/2012
Aug, 27. 2012 12:45PM
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Div of Criminal Investigation
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INo,Lill 06 1P, Ll/1
STATE OF YOWA
mvu��rCriminal Hlotory Record Checks
Reqtxest Form
DC1 Accountbo,;
To: IOWA )Division of Criminalinvestlgatton
Support OperationsBoreav, V.Moor
215g, 111 street
Do Moines, lowa 50319
(SU) 725.6066
(515) 725-6090 Rx
Last
From: CITY OF IDWA CITY
CITY CL$A.IC'9 OFFICE
410 Y. WASHINOTONSTRIMT
IOWA CITY XOWA 52240
Phono; 319356-5041
Fax: 319356-5497
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Aate of Birth fnlandalorvf I VxMderlmandelom) I Social SecurINNumber Geeon,me„aedl
c`,'5 -12-,5-'11V73 I LgMaie El17emale I %s 6- o I ..,, � Z 11j
Waiver.Iiafomilldon.. Without a signed weiverfrom the subject ofilia request, acomplete criminal histoiyrecordmay not I
he releasable, per Code of Iowa, Chapter 692,2, $'or complete criminal history record information, asalloWed bytaw, ahvays
Afatn a waiver signature front the sub lect off h a reauest
WrahigY.RdAMSa. I hucby glue ren„ isslmt 1br tho above regaesting oHiofaI to cm, dud an rows cdInInat lihiory record check wilt l,e Dlvlrton of Criminal
Inrasilgatlon (DCI), Any uimtnaf hluory data conecmingn,e (hatls nlalniolAcd 6y theDCl niay be released es allowed bylaw.
Waiver
XoNva Criminal .History record Check Results
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As of a search of tha provided Hama and date of birth revealed;
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• •• ;
1 �I No Iowa Ciiminal T•l .stoxy ltecozd found wlth DCT
Iowa Criminal Mstory Recoxd attached, DCI #
'
DClinitials—VEL
teceived Time Autt;.J./,2012 3:12PM No, 1851
Iowa Department of Transportation
Office of Driver Services (Toll Free) 8041-532-1121
FO Bax 9204, Des Maines, IA 50305-9204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
8/29/2012
DL/ID #:
373AE0142 (IA)
Customer #:
5546452
Name:
Elhassan, Omer Mohamed
Class:
D
ID Status:
None
Address:
1269 SWISHER ST
Audit #:
5569375
DL Status:
VAL
Issue Date:
10/13/2011
CDL Status:
None
City/State:
IOWA CITY, IA 522451592
Expiration Date:
05/25/2014
CDL Cert Status:
None
Endorsements:
2
CDL Med Status:
None
Mailing Address:
1269 SWISHER ST
Restrictions:
Corrective Lenses
Restriction
None
Date of Birth:
5/25/1973
Supplement:
Mailing City/State:
IOWA CITY, IA 522451592
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Elhassan, Omer Mohamed DL/ID: 373AE0142
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: Elhassan, Omer Mohamed DL/ID: 373AE0142
8/29/2012
cvl�v-vl e4
Office of Driver Services
Iowa Department of Transportation