HomeMy WebLinkAbout12-205III
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-182
356-5040 /kms ell' I
FAX
Authorization Number / �?_ — d OG -
(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 �n,ff�1 �r Last nn
1. Name ,��AL t l(vh /(41-M J1yi/sQ�
2. Mailing Address S"y- S S v Ci ky .� L r� Z Z Lt'
3. Telephone: Home )9) gS S - �f17L4 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? N
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 Where When
7. Have you been convicted of any traffic offenses in the last five years? (,j c
Tvpe of offense Where When
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? /V
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)
n/0
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)
danna.iddm�g 06/2012
I hereby certify that I haze issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
,J ,< QA `)97 ( Z . I understand that if I falsely answer any questions in this application, that this A
applicatioll rKay 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) _ N
Signature of Applicant\� v Date 01/1-2/q, i 2
RYF*R[RRi4RYffY###Y#4#####34#413#N4R##*##R*RR#YRR[I*fRR**111111#1H111111N1fff##f#4fR##4#######}**RRRFF3RRf*R3[11fYYfY#Y##1!##Y#RY#####4*3#4**
STATE OF IOWA )
COUNTY OF JOHNSON )
p
scribed and sw rn to before me by r �u e— On this ) day of
^L -D- -
KELLIE K. TUTTLE Y« 1,� re—
TU
e—
Commission Number221519 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.
*tfffffffitffllf*4f##*#H####*#4#F4****f*ff3fiM*fffffi#1111111414#f###4H#N#4######i###**t****3***f**Rf1**fff*1*fYf*ff!!#*N4#f4**#4*##*#ti**if
Office Use Only
Approved application
DCI report
State certified driving record
Website update
detlNaxidrivbadge pp2 10.dm 06/2012
Iowa Department of Transportation
Office of Driver Services (roll Free) 800332-1121
PO Box 9204, Des Moines, IA 503W9204 515-244-9124
FAX: 515-239-1837
Inquiry Date: 9/4/2012
Name: Ahmed, Sue Ellen Nalem
Address: 1269 SWISHER ST
City/State: IOWA CITY, IA 522451592
Mailing Address: 1269 SWISHER ST
Mailing City/State: IOWA CITY, IA 522451592
Convictions
Certified Abstract of Driving Record
DL/ID #:
258AD8762 (IA)
Customer #:
5420516
Class:
C
ID Status:
None
Audit #:
5630353
DL Status:
VAL
Issue Date:
11/15/2011
CDL Status:
None
Expiration Date:
03/02/2013
CDL Cert Status:
None
Endorsements:
NONE
CDL Med Status:
None
Restrictions:
NONE
Restriction
None
Date of Hirth:
3/2/1983
Supplement:
Sex:
F
History Information
Citation Date Conviction Date ACD Explanation County 3UR
05/23/2009 08/24/2009 593 :Speed IL
Name: Ahmed, Sue Ellen Nalem DL/ID: 258AD8762
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:
;� "••"•��/'4
9/4/2012
D
IOWA Viz
.''
D. T.
f "••'• S
Office of Driver Services
Iowa Department of Transportation
Name: Ahmed, Sue Ellen Nalem DL/ID: 258AD8762
Sep.11. 2012 2:55PM
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Div of Criminal Investigation
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Received Time Sep, 4, 2012 2:19PM No, 2658
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