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HomeMy WebLinkAbout12-194�r III Mccrz CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 3S6-5040 (319) 356-S497 FAX 1. Name First t 2. Mailing Address Z. 44 © l Authorization Number I 2 - tq (Office Use Only) APPLICATION FOR TAXI DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday.) Middle A b a alb c,,\ J AVT,2W 3. Telephone: Home 31 c1- Sq y — gq 6g Other. 4. Prior experience in transportation of passengers: J(L Last i i 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? / v 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? -,L L' Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When SPtfed �'F_\-N&—ZTO 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? yJ {, 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) /,J 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) derk idrivbadg OW012 a I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number . 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 3 g©1 80 2 Date q—!�_ 2O) Z *kRR}#R#**R*w+R**xw}RR}*w}}ww###4####w##4+++++##+#++++#+##*#+##+##*+#x+**}}*R***xRk*RR*RR##*R**R**x*w}wxxx*xx4#x4w+####4####+++++++++++#*+*xRx+R STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by A% 4" ! Ma 4vv, T On this day of Si o =SONDRAEF'�ybcNota Public in and for the State of Iowa Notary 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). 2i'1C� of Poli ief or designee Date Df Ch Clerk or designee 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 06/2012 J State of Iowa Division of Criminal Investigation 215E7'hSt Des Moines IA 50319 Ph. 515-725-6066 Fax 515-725-6080 Iowa Criminal History Record Check Walk -In Request Your name 2e r Address ZLAOLA T `Z" City/State/Zi Ow ' j- — Z Phone# Requesting an Iowa criminal history record check on: Fill in all shaded areas. Last Name Apellido (mandatory) First Name Primer Nombre (mandatory) Middle Name Segundo Nombre (recommended) M �( \�(DO Y\11 r/p131- L�- �6dc 1G Date of Birth Fecha Nacimiento (mandatory) Gender Genero (mandatory) Social Security Number (recomnmended) Wiale []Female Waiver Signature Firnra (If the request is on yourself, please sign. If the request is on someone else, write N/A.) [%(6 az�' DCI USE ONLY Results 11 As of a name and date of birth check revealed: r-> a - - C") 96o record found r� ❑Record attached, DCI # -` DCI initials N ut Receipt Number of requests x $15.00 per last name = Total amount $ 1 5. UD Method of payment: ❑cash ❑money order El check # OMasterCard or Visa Cardholder's name O a b c c -k M Gr%10OM Last 4 digits of MC or Visa q. Li S 2. DCI initials Credit Card Number # Exp. Date Iowa Department of Transportation Office of Diner Services (Toll Free) 81711-532-1121 PO Box 9204, Des Moines, IA SD3W-112G4 595-244-9124 FAX: 515-239-1837 Inquiry Date: 9/5/2012 Name: Marhoom, Nabeel Abdalla Address: 2404 BARTELT RD APT 2A City/State: IOWA CITY, IA 522462704 Mailing Address: 2404 BARTELT RD APT 2A Mailing City/State: IOWA CITY, IA 522462704 Convictions Certified Abstract of Driving Record DL/ID #: 380AE8021 (IA) Class: D Audit #: 4750353 Issue Date: 10/15/2010 Expiration Date: 03/18/2014 Endorsements: 3 Restrictions: NONE Date of Birth: 3/18/1979 Sex: M History Information Customer #: 5550441 ID Status: None DL Status: VAL CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: Citation Date Conviction Date ACD Explanation County JUR 09/06/2010 _ ,10/18/2010 ;S92 ;Speed 48_"IA .--- Name: Marhoom, Nabeel Abdalla DL/ID: 380AE8021 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: ;.•......... '1 9/5/2012 0. ID. f�R Office Driver Services S of '���I�-- Iowa Department of Transportation Name: Marhoom, Nabeel Abdalla DL/ID: 380AE8021