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HomeMy WebLinkAbout12-204Authorization Number \ -�I' 'JDL�t % 1 (Office Use Only) '+ memo Il �.✓14_ APPLICATION FOR TAXI DRIVER CITY OF IOWA CITY (Police Department review must be made 410 East Washington Street between 8 a.m. to 3 p.m., Monday— Friday.) Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX First yo Middle p ,. Last 1. Name ke�1 u�CV 2. Mailing Address 11V7 R 6 PY a 0C- /o cs A Cc lto f A 15 2_2_14 3. Telephone: Home 3! c/ 3 Z I fG 1 2 Other: 4. Prior experience in transportation of passengers: 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? Nei Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? NC, Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /\J✓ 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) tv o 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) d.M .Idni batlg 06/2012 I hereby ce that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 14-65 1-' _70 8 6 . I understand that if I falsely answer anv nuestinns in this nnnliratinn that thic 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;i�!� Date 0 9, a � - i 2 STATE OF IOWA ) COUNTY OF JOHNSON 1 scribed and sworn to before me by I ► ID ftCU1( �Q� lam. On this te day of 0 i �i KFLUF K, TUTn E s`r i;, ..,.,mission Numbe.�ves19 otary Public in and for the State of Iowa k4h4444444444444#*#*#************4Xk4k4444##*##***#***#****************444444*#44####*#***#*#***##**********44444###*#**#*#****#*******44*44444* 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. Office Use Only Approved application DCI report State certified driving record Website update c1erWWidrivbadgeapp2010 doc 06/2012 Aug. 29, 2012 3:OOPM Div of Criminal Investigation .✓ ••- o•,. c v I n I c T n n 1 . I l r V I c I a V I L I V I I U Rd VI l I STATE OF 1 1 `11 ( '1 ;I HistoryRecord Check ��ii101/A�i I\I ' VO!, Request .:.1 I 1 �, kr•'r��.J Tot Iowa Division of Criminal InVesllgatlon Support Operailons )iureau, 1" Fio or 215 PD. I"' A(reet Des Moines, Xown 50319 (515)726-6066 (615)125-6090 Fox 'LS K 1 am reaves r RA No, Zllpg7 77 F. L3 DCIAccountNumber: Lt -6 o � ^ F grapplloable) From: CITY OF IOWA CITY oITYt' CY,19R r'S OU10B 410 E, WASHINGTON STIM,T IOWA CITY IOWA, 52240 Phone: 319-366-5041 Fax: 319-356-9497 Middle Name a tl _/' — 116 2 I BMale ©Female Z t� •_ 5 5 g Z IWaiveF.!'i(foHnallon: WI(houta signed waiver from the subject of the regaest, a complete criminal history rocord may not I beretoasable,per CodeofIowa, Chapfer692,2.Forcomp le criminal history record informadon,asallowed bylaw, always obtain a walver sIgnofure from the sublect of tha reauest l' �aiV¢Y.Releas`6: Iha6yglvc parnifulon fertile above eaquesting ogclat to oandoct in Iowa cranlnal hlnolyrecord checkwhh dioNvislonoecdMinal Invesllgalion (Ml). Any criminal h1trary data conca tingnio Mot Is maintained by (he Wf may be rakued as allowed bylaw, Waivei- Signithire, A.vrvµ IAAMAKAAQ •^-OLVAr A.-UUI /ALL'1,116VR\JI.dFYLLAL`J (DCIU;Udy) As ofa search of the provided namo and date of birth revealed: N LET No Iowa Criminal history Record found with DCl ^.If..: �1 :T ✓1 13 Iowa Criminal History Record attached, DCT # DCl initials ieceived Time.Aua. 21. 9n12 12:50PM No. 2139 W111_1, �I)%/L.l/1bi tIowa Department of Transportation Office of Driver Services (Toll Free) 800-532-1121 PO Box 9204, Des Moines, IA 50306-9204 515-244-9124 FAX: 515-239-1837 Inquiry Date: 8/29/2012 Name: Elamin, Mohamed Bakri Mohamed Address: 1637 ABER AVE APT 8 City/State: IOWA CITY, IA 522464729 Mailing Address: 1637 ABER AVE APT 8 Mailing City/State: IOWA CITY, IA 522464729 Convictions Certified Abstract of Driving Record DL/ID #: 465AF7080 (IA) Class: D Audit #: 5833570 Issue Date: 03/02/2012 Expiration Date: 09/13/2012 Endorsements: 3 Restrictions: NONE Date of Birth: 9/13/1962 Sex: M History Information Customer #: 5751120 ID Status: None DL Status: VAL CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: 02/09/2009 Citation Date Conviction Date ACD Explanation Count, JUR 110/09/2008 02/25/2009 S93 Speed MD 101/08/2009 02/09/2009 M41 Improper Lane Use MD 11/16/2009 03/15/2010 N31 Fail to Yield Right of Way MD '11/20/2010 12/06/2010 N63 Driving Wrong Way on One Way Street 52 IA 04/03/2012 06/08/2012 S92 Speed 52 IA Name: Elamin, Mohamed Bakri Mohamed DL/ID: 465AF7080 I 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: p "'""•:!`/�h� 8/29/2012 IOWA =OKSMV D. 0. T.;."% 0"J� ,w�R� �=$� ' Office of river eof Services • Iowa Department Name: Elamin, Mohamed Bakri Mohamed DL/ID: 465AF7080