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Home My WebLink About12-1864 l 1 .IF- - -4 CITY OF IOWA CITY 410 East Washington Street Iowa a 52240-1826 9) 356-504 g)2-3 (319) 356-5497 FAX Authorization Number /—/d (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 04jtiA y- t 2. Mailing Address 3. Telephone: Home 3Ij — Ltyu—°l3 ;7 L4 Other: 4. Prior experience in transportation of passengers: Yds 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 -,� Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? ^1 e5 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 n Tvve 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) cle"uidmbdg 06/2012 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number h NNS Fr 7 7 h,L . 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 7 J Date o c/ / 2 o I a STATE OF IOWA ) COUNTY OF JOHNSON ) S scribed and swoW to/ before me by �✓ t ( /Q� ✓ aS / On this / ' " ` day of KELLIE K. TUTTLEI 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). V"44 Si nature of olicelief or des' ignee Signa -fare of City C rk or designee eN-/e2 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. ar#rar#H#rH#H##ra#rrr#HH+++HH+H++aaa*aa*aa*aHH**aH#Hr*Hara*HaH*Hr*rH*raH+rr*H*#ar*#Hr##Hrraaarrr#H#H#rrr##rr#HH###+++a* Office Use Only Approved application DCI report State certified driving record Website update dMMWoa;waaoeappzoio.m 06/2012 4 Iowa Department of Transportation Office of Driver Services (loll Free) ON -532-1121 4 PO Box 9204, Des Moines, PA 50308-9204 515-244-9124 FAX: 515-239-1837 Certified Abstract of Driving Record Inquiry Date: 8/17/2012 DL/ID #: 549AG7752 (IA) Name: Elgorashl, Amar Elmustafa Class: D Address: 209 HOLIDAY RD APT 131 Audit #: 5566808 Restriction None Issue Date: 10/12/2011 City/State: CORALVILLE, IA 522414003 Expiration Date: 03/26/2016 Endorsements: 3 Mailing Address: 209 HOLIDAY RD APT 131 Restrictions: Corrective Lenses Date of Birth: 3/26/1984 Mailing City/State: CORALVILLE, IA 522414003 Sex: M History Information CLEAR DRIVING RECORD Name: Elgorashf, Amar Elmustafa DL/ID: 549AG7752 Customer #: 5876365 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, 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 sdid 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: S.:•"'•••:�T/�,�ry 8/17/2012 IOWA ' y°� Driver Services y Qpm S Office of titer Iowa Department of Transportation Name: Elgorashi, Amar Elmustafa DL/ID: 549AG7752 Aug.24. 2012 4:27P Div Div of Criminal Investigation No.2074 P. 2/6 nUg, I/. N12 4. IUiu btty bl CIB ' bl t 0 1u&d U L IVa. LI JN f. L in LOIN STATE OF IOWA -- cCrrillai aal ffistory-Record (Check Request Form DCiAccountNutnber; �-_a (ifeppllceb(o) Tot 101yn Dlvislon of CrWrtal Investigation From; CITY OF IOWI MY Support Operationg Bureau,V'Floor . CITY CLT•RNISOFFXCF 2161;. 7d' Street 41019. WASMOTON STREET 1)osMoines,7owa 50319 (615)725-6066 IOWA CITY IOWA 5224D (515) 725-6000 Fax Phone: 319.356-5041 1eax: 319-356-5497 I all -L r0VO8tL,qg alaIowa CominalMstoryRecord Cheek a%- Last Name mandatory) -MrstNarne mandatory) Middle Name recommuldo ��5o�ro�•5�1 /�w�.y %�mus1'� Date of Birth eneafat}j Gender mandato Social Security Number(rewo,mcnded) ®Male dlfelnale JVa1ver-Tgf0.v ,7flop:Withoutasignedwaiverfromthesubjectoftherequest,acompletecriminalhistorytrocordmaynot he releasable, per Code oflown, Chapter 692.2, For compid criminal historyrecord information, as allowed bylasy, always obtain a waiver sign aturo front tj(o subectoftherequest WaiVeJ 61eaSEr Themby give pemifsylottfor the abova requesting offictef to conduct an tows criminal history mWrd eheckwh1i theDtilslon olQtimfnef ynvrsligation (DCI). Any wlmhml Idctgry data conmrningum (fiat is maintained by tho PQ may 6e released as allowed bylaw. 1�alverSfgnafure: Iowa Cxi>rninal History Record Cheek ReSlXltS (MUfaaniy) N) As of1�/2Yb;P, a,seaxch of the provided name and date ofbirihxevealed: :,Z- :r. rn c• o5 Sq, N li n No lows Criminal I3istory Record c found with DCX t < ® lava. Cximinal.MatotyRecord attached, DCI# = 7: N DC>: initials Received Time Au�,i�117, k012 4;18PM No. 1629 r�T nn