HomeMy WebLinkAbout12-195� mp
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
/1. Name First
Authorization Number 19--195-
(Office
9-_//S
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
Middle
2. Mailing Address 2 l n & ( t: e-/� VA) /q,il
3. Telephone: Home _?( s44 0,n e�L Other:
4. Prior experience in transportation of passengers:
Last
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?
Type of Offense / 1Where When
/'t
7. Have you been convicted of any traffic offenses in the last five years? See ZP&
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /'N3
Type of offensep Where When
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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)
deikttadddvWg 06/2012
I hereby ce i tha I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number%
ri �l 1O, 3 . 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 oft r (visions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public)
Signature of Applicant Date�0-
STATE OF IOWA )
COUNTY OF JOHNSON )
nIto before
r
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).
Signature & Police Chief
�ordesignee
Signalerk o' r designee
% b -/Z
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
deddtaxiddWadgeapp2010,d 06/2012
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.2012 2'2�PM Div of Criminal Investigation No,9065 P. 6/6
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STATIF, OV IOWA
jj Cl"asua3xa��,Jf3Li��Om� �@ecOtrd (check
Request Form
To; Iowa bly(slonofCriminal Ynvestfgntforn
suppoyt opoyal)ons 11(i ow, i'' Plooy
2fsR T� Street
De!I XOl1(69)i0WA 50319
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(575 725-6090 k`arc
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Iowa Criminal Maiory Record Cheek &2�
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As of ��r/J��
a seOLch oPthepxovided name and data of bilthsevaAlcd:
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NoTowaC.limJnaII-istoryRecordfatmdwith DCI
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El IowaallminalNistoxyRecord attached,I)CY#
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ieceived Time Aug. 9. 2012 6:040 No. 1094
C
Iowa Department of Transportation
AO Office of Driver Services (Toll Free) 800332-1121
PO Boz 9204, Des Moines, IA 50306-9204 515-244-9124
FAX: 515-239-1037
Certified Abstract of Driving Record
Inquiry Date:
8/16/2012
DL/ID #:
542AG9038 (IA)
Name:
Khames, Mohamed
Class:
D
Address:
2540 BARTELT RD APT
Audit #:
5429038
2C
Issue Date:
08/09/2011
City/State:
IOWA CITY, IA
Expiration
08/09/2013
522462723
Date:
Endorsements: 3
Mailing Address:
2540 BARTELT RD APT
Restrictions:
NONE
2C
Date of Birth:
1/6/1974
Mailing City/State:
IOWA CITY, IA
Sex:
M
522462723
History Information
Convictions
Customer #: 5863128
ID Status: None
DL Status: VAL
CDL Status: None
CDL Cert None
Status:
CDL Med None
Status:
Restriction None
Supplement:
Citation Date
Conviction Date
ACD
Explanation County JUR
01/17/2012
03/27/2012
S92
vSpeed IA
02/24/2012
05/04/2012
IS93
_ ,52 _
;Speed 52 IA
Name: Khames, Mohamed DL/ID: 542AG9038
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:
......... /d;'4�
8/16/2012
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D. 0.
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Office of Driver Services
+�......
Iowa Department of Transportation
Name: Khames, Mohamed DL/ID: 542AG9038