HomeMy WebLinkAbout12-214CITY OF IOWA CITY
410 East Washington Street
Iowa C 40-1826
(3 19) 356-5497 FAX
First
1. Name "f1+6t Fp ,V4 -n
Authorization Number / � —0-/ C/
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
2. Mailing Address iKdW _.7,v CA
3. Telephone: Home 3 )c- 353- S��S Other: _q9,0 —
4. Prior experience in transportation of passengers:
�..-(NK2)("4S 4o x i dy'(yx_4- w) ars col, -
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
?ax: Y/e l 4 r.
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? N_
Type of Offense
Where When
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? No
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)
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I hereby cg 'fy that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number,
V,�Gi � A SQL} 7� . I understand that if I falsely answer any questions in this application, that this'
appTicatio6 may a c5erfled. 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 Applican Date
STATE OF IOWA )
COUNTY OF JOHNSON )
SLscribed and sworn to before me by \ �� cs�caS e w �} �^2 wa V� On this day of
C��
Notary
1
Euplic in and for the Stat Iowa 713114
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).
/1
Signature of'Police Chief or designee
Signature of City Clerk or designees
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
deddtaxidwv dgeapp2010.dm 06/2012
Iowa Department of Transportation
'r h Office of Driver Services (Toll Free) BM -532-1121
PO Box 9294, Des Manes, IA 51)3D&9204 515-244-9124
FAX: 515-239-1837
Inquiry Date: 9/11/2012
Name: Efreiwan, Motasem
Address: 438 HAWKEYE CT
City/State: IOWA CITY, IA 522462809
Mailing Address: 438 HAWKEYE CT
Mailing City/State: IOWA CITY, IA 522462809
Convictions
Certified Abstract of Driving Record
DL/ID #: 504AG8847 (IA)
Class: D
Audit #: 5501978
Issue Date: 09/10/2011
Expiration Date: 03/01/2013
Endorsements: 3
Restrictions: NONE
Date of Birth: 12/30/1986
Sex: M
History Information
Customer #:
5804331
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Citation Date Conviction Date ACD Explanation County IUR
09/17/2011 09/29/2011 .592 .Speed 52 IA
Name: Efreiwan, Motasem DL/ID: 504AG8847
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:
;."""•tid'',4
9/11/2012
IOWA ¢'v
1.
D. O. T.
.••lt-
Office of Driver Services
BflIYENI
Iowa Department of Transportation
Name: Efreiwan, Motasem DL/ID: 504AG8847
State of Iowa
Division of Criminal Investigation
215 E 7fh St
Des Moines IA 50319
Ph. 515-725-6066 Fax 515-725-6080
Iowa Criminal History Record Check
Walk -In Request
ReauestinR an Iowa criminal history record check on:
Fill in all shaded areas.
Last Name Apetudo (mandatory)
First Name Primer Nombre (mandatory)
Nliddle Name Segundo Nombre (recommended)
I�e��gh
M)te
�0�Se�
Date of Birth Fecha Nacimienro (mandatory)
Gender (mandatory)
.Social Security Number (recommended)
130 (� q 0 o
GeGenero
L1Male ❑Female
3f C{
Waiver Signature Firma (If the request is on yourself, please sign. If the request is on someone else, write N/A.)
Oel USE ONLY
Results
As of �'{
a name and date of birth check revealed:
N
No record found
U, -°
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❑Record attached, DCI #
z
DCI initials
c
Receipt
A
Number of requests A x $15.00
per last name = Total amount $ JSCD
Method of payment: *ash
❑money order ❑check #
❑MasterCard or Visa
Cardholder's name
Last 4 digits of MC
or Visa
DCI initials
Credit Card Nurrlper # Exp. Date