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HomeMy WebLinkAbout12-207-4 -k me®r�1\ CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX Authorization Number APPLICATION FOR TAXI DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday.) /a-C';�O7 (Office Use Only) �/_ lFirst � Amt M11-4 al (� of Gln 1. Name / 2. Mailing Address' (� �IV 1( <' - opps� N � I T_ © W et Cl, iq 5� � O 3. Telephone: Home 3 1- 3 3-3 — b LY Other: V ( 4. Prior experience in transportation of passengers: T_ I \I e --7-A X, ( / N � u Ac-( 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? %V' b 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? Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? 7 r Ci Type of offense Where When 8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? b 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) derkA ,addwad9 06/2012 I hereby certify that I have y wd/to me by the Iowa Department of Transportation a valid Chauffeur's license number 1 �% i5 ` �7 . I understand that if I falsely answer any questions in this application, that this application may bed. 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 ) 1 STATE OF IOWA ) COUNTY OF JOHNSON j and sworn to before me by r—L t;6r ay /—(k N cZa H . On this day of SONDRAEFORT immission Number 158791 My commission Expires Notary Public in and for the State of Iowa ****########*#######*######*##*##############*######*######*#**#******##************************************+#***###*##+#*###############**#**#* 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). 519J0a Date %'-/3 - /.p_ 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 Identi!-cation cards. Office Use Only Approved application DCI report State certified driving record Website update cledviaxiddv geapp=ftdm 06/2012 State of Iowa Division of Criminal Investigation 215E7t"St Des Moines IA 50319 Ph. 515-725-6066 Fax 515-725-6080 Iowa Criminal History Record Check Walk -In Request Your name T) � ct' Address 6 6 N 5 '/'a N ST \ C;- UJ OL C -i -r City/State/Zip I o r..) ct G j T T q-14 0 Phone# 3 t 1 - 33.3 - 4t 9f 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) Date of BirthhFecha Nacimiento (mandatory) Gender Genero (mandatory) Social Security Number (recommended) 61 2l 1 72 WVIale ❑Female ]� _ ` g 3 - 9-1— " J 0I Waiver Signature Firnua (If the request is on yourself, please sign. If the request is on someone else, write N/A.) DCIS JF ONLY Results N _ -- N y As of o a name and date of birth check revealed: ° No record found -+ ca ❑Record attached, DCI # Cl) DCI initials Receipt Number of requests x $15.00 per last name = Total amount $ $. DO Method of payment: Ocash ❑money order El check # El MasterCard or Visa Cardholder's name Last 4 digits of MC or Visa DCI initials Credit Card Number # Exp. Date Iowa Department of Transportation Office of Driver Services (Toll Free) 800-532-1121 PD Box 9204, Des Moines, IA 50306-9204 515-244-9124 FAX: 515-239-1837 Inquiry Date: 9/6/2012 Name: Abdallah, Elfatih Hussein Address: 2604 BARTELT RD APT 1C City/State: IOWA CITY, IA 522462728 Mailing Address: 2604 BARTELT RD APT 1C Mailing City/State: IOWA CITY, IA 522462728 Certified Abstract of Driving Record DL/ID #: 617XX3816(IA) Customer #: 2345972 Class: A ID Status: None Audit #: 5250474 DL Status: VAL Issue Date: 05/25/2011 CDL Status: VAL Expiration Date: 06/21/2013 CDL Cert Status: None Endorsements: TX CDL Med Status: None Restrictions: NONE Restriction None Date of Birth: 6/21/1972 Supplement: Sex: M History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number ]UR 11/20/2008 472653 IA 06/24/2010 578332 IA 12/_03/2QL1 660530 _ IA Name: Abdallah, Elfatih Hussein DL/ID: 617XX3816 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: -- ••:w/ h� 9/6/2012 IOWA10. .:0 *y r r ......Office of Driver Services Iowa Department of Transportation Name: Abdallah, Elfatih Hussein DL/ID: 617XX3816