HomeMy WebLinkAbout12-196i A"
CITY OF IOWA CITY
410 East Washington Street
Low 52240-1826
319) 356-504 Si31
(319) 356-5497 FAX
First
1. Name \,-\ cak
2. Mailing Address
Authorization Number / oe — / I?&
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
Middle
3. Telephone: Home r S 9(Tp�
4. Prior experience in transportation of passengers:
Other:
Last
(Office Use Only)
k"
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? Yl ZS�I
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? j2 r -,✓.6
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? Y \ o tv-\�
Type of offense Where When
SnGr.I 7-a4-
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Yt- pVvP-
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)
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)
der uldrivb g 06/2012
I hereby certify that I h.ye issued to me by the Iowa Department of Transportation a valid Chauffeur's license nember
11 `4-7tZ I� �� ` . I understand that if I falsely answer any questions in this application, that this'%
application ay be denied. 1 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 pro�Cisions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public) t
Signature of Applicant 1�� X Datey7-\ _ o !v _ /',
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by r 50 . On this _ day of
SONDRAE FORT Is G.nlb
o® Commission Number 159791
U. r. m [I.dM E1mkes Notary 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).
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.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
.1., a dmbadgeapp2010 d. 0612012
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Aug.29, 20121 3:O1PM^ Diyrof Cniminal YnvestUgatUooy NU, X10) P; 8
STATE OF IOWA
Criminal (story Recoral (Check
Request Form
To: Towa DIV1910n of Crlminal Investigation
support Operations $nrean, 1")Rjoor
21539; 7o'S&oet
Des Moines, Iowa 50319
(519)'W-6066
(515) 726.6080 Fax
I ainreaaesiintr an Iowa G]imitralHbtorvRecord Cheak ori:
DCI Accountblumbof: 'l M'r
(lreppllcarle)
Vromt CITYOVIOWACITY
CITY WgRX's OF21CA
410 F, WASMNGTON 9TI2TtkT
IOWA CITY IOWA 52280
Phone: 319-356-5041
1?axo 319-356.9497
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Wal'vew2-nfoyrraattont Without a signed ywyer from the subject of the requost, a complete ctlmtnal history record may not
be yoloasable, per Code of Tow, Chapter 692.2. For com lee 0Iminal history raeord Information, as allowed Bylaw, alwaya
Walvap.Itelea4e:ILeitbygivepenntssroufor Ilio Am
InvasdGatlon(DCI). Any uimfnglldstorydstaconcemingme
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As of asearch ofthoproYldednamoand date ofbirth revealed:
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No Iowa Cailnlnal History R ecozd found with p CX
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13 Iowa Criminal $istol:y Record attaohed, DCI #
r
m
DCI initials_
RP.CP;vPd Timp.. Aue.97_ 7019 16MAM Nn. 911R
CA
Iowa Department of Transportation
Office of Driver Services (Toll Free) 80U-532-1121
FO Box 9264, Des Moines, IA 5031)"264 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
8/21/2012
DL/ID #:
137880959 (IA)
Customer #:
4102089
Name:
Salih, Nagmeldin
Class:
D
ID Status:
None
Mohamed
Address:
2548 INDIGO DR
Audit #:
6175614
DL Status:
VAL
Issue Date:
08/01/2012
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
08/04/2017
CDL Cert
None
522406808
Date:
Status:
Endorsements: 3
CDL Med
None
Status:
Mailing Address:
2548 INDIGO DR
Restrictions:
NONE
Restriction
None
Date of Birth:
8/4/1967
Supplement:
Mailing City/State:
IOWA CITY, IA
Sex:
M
522406808
History Information
Convictions
Citation Date Conviction Date ACD Expianatlon County 3UR
11/28/2010 07/26/2011 592 :Speed IN
Name: Salah, Nagmeldln Mohamed DL/ID: 137880959
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:
: •""••:'�%4i� 8/21/2012
10
WA
D.O.T
.0TIsR
04 t
.'
Office of Driver Services
Iowa Department of Transportation
Name: Salah, Nagmeldin Mohamed DL/ID: 137680959