HomeMy WebLinkAbout12-208CITY OF IOWA CITY
410 East Washington Street
Iowa Cit Iowa 52240-1826
(31 9) 356-504 CALL f-21pgy N1oRNIN6
(3 19) 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.)
ra - goe
(Office Use Only)
First Middle 1 Last
1. Name On lco( tedy
ka.0'2
2. Mailing Address :;74) �_ is ���g�f . t.x,
3. Telephone: Home ti\c1LA--bri Z41 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? _ q
Type of offense
Where
6. Have you been convicted of operating a motor vehicle while under the influence of
years?_
Type of Offense Where
7. Have you been convicted of any traffic offenses in the last five years?
When
or drugs in the last five
When
Type of offense Where When
8. Has your drivel's license or chauffeurs license been suspended or revoked in the last five years?
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)
deWw1ddvbadg 06/2012
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
)s1 o Ah 7 (j . 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 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 �� — �� Dated / 1
STATE OF IOWA )
COUNTYOFJOHNSON )
Subscribed and sworn to before me by T bra b;: 0an � On this /,3 day of
S aoia r
s SONDRAEFORT SR d,,4 F�
i Commission Number 159791
". P—mii+i.,,, =..,� 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).
Signa re of Plif Chef
or designee
Signature of City Clerk or designee
Date
y-/3 -/a.
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
deck idnvbadgeapp2010 do 06/2012
CA
Iowa Department of Transportation
Office of Driver Services (rDll Free) 800-532-1121
PO Box 9204, Des Moines, IA 50306-92M 515-244-9124
FAX 515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 9/4/2012 DL/ID #: 240AD9724 (IA)
Name: Ibrahim, Omar Ibrahim Class: D.
Mohamed
Address: 707 W ESTGATE ST Audit #: 5900223
Issue Date: 04/04/2012
City/State: IOWA CITY, IA 522464638 Expiration 10/10/2014
Date:
Endorsements: 3
Mailing Address: 707 WESTGATE ST Restrictions: NONE
Date of Birth: 10/10/1975
Mailing City/State: IOWA CITY, IA 522464638 Sex: M
History Information
Convictions
Customer #: 5389467
ID Status: None
DL Status: VAL
CDL Status: None
CDL Cert Status: None
CDL Med Status: None
Restriction None
Supplement:
Citation Date
., ..._.- ...M...
Conviction Date
ACD
Explanation
County
SUR
_
04/02/2010
_-. _ _..... - .___..._.
'.05/14/2010
..
N83
.._....... ,.._. .... _ _. _. __................
Improper.Start _—
_ 52
_._
IA
10/23/2011
112/05/2011
M14
Fall to Obey Traffic Slgn/Signal
52
IA
Sanctions
Type__ Effective_ End ACID Explanation _ _ _ _ Occurrence IDR _ JUR
Suspended -1
3/13/2012 ,03/27/2012 -D53 Non -Payment of Iowa Fine � � 'IA ..�. _ IA
Name: Ibrahim, Omar Ibrahim Mohamed DL/ID: 240AD9724
Pursuant to Iowa Code 4321.10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify
that 1 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:
Z
3*;
IOWA°
o;D.0 T.
rt�n�F D91VE9 S�Qsr
Name: Ibrahim, Omar Ibrahim Mohamed DL/ID: 240AD9724
9/4/2012
Office of Driver Services
Iowa Department of Transportation
Sep,12, 2012 10:35AM Div of Criminal Investigation
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Received Time Sep. 4. 2012 9:32AM No. 2603
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