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Home My WebLink About12-215CITY OF IOWA CITY 410 East Washington Street Iowa C1 Iowa 5224q I876 9) 3s6 -so �q/,y (319) 356-5497 FAX Authorization Number — a (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 Last 1. Name 2. Mailing Address 0 MI Ie VF 61A�&e' 3. Telephone: HomeOther. i 4. Prior experience in transportation of passengers: 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? / V 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? 411) Tvpe 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 drivers license or chauffeurs license been suspended or revoked in the last five years? /V -) Tvpe 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 CERT TIFIED 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) cle` midrivt dg 06/2012 0 I hereby certi tat I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number c2 y�7 . I understand that if I falsely answer any questions in this application, that this 1 appli tion may a deni d. 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 ofApplicantQ/r%6111" Date Y11azI Z r, STATE OF IOWA ) COUNTYOFJOHNSON S scribed arild sworn to before me by V(Ver 1�1__l 1 hL On this I� V day of i "u�nt KELLIE K. TUTTLE 'C L-�. (-� 1� LL C I s's Commisso N�. 8fX?es19 Notary Public in and for the State of Iowa pie 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). 724� 4 q —Idl -/.L Sign ture of P lice CIW or designee - / Date Signat re of City Clerk or clesignele 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 derlNaxidrivbadgeap 20104 06/2012 State of Iowa Division of Criminal Investigation 215 E 7" St Des Moines IA 50319 Ph. 515-725-6066 Fax 515-725-6080 Iowa Criminal History Record Check Walk -In Request Your name Q Sec Address Z 6 o W est t cu k0 AVE Ci /State/Zi o Phone# Recuestine 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) CLh�� Date of Birth FechaNacimienro (mandatory) Gender Genero (mandatory) Social SecurityNumber (recommended) � bmMale ❑Female Z26 — — 5 -L7 Waiver Si nature Fir na (If the request is on yourself, please sign. If the request is on someone else, write N/A.) KI USE ONLY hJ O Results As of F a a name and date of birth check revealed: M' =' No record found c ,- �. W3 y ❑Record attached, DCI # - r DCI initials Receipt Number of requests -1 x $15.00 per last name = Total amount $ S. cc) Method of payment: JOcash ❑money order ❑check # MasterCard or Visa Cardholder's name Last 4 digits of MC or Visa DCI initials 14 Credit Card Number # Exp. Date Iowa Department of Transportation AW Office of Driver Services (Toll Free) 606.5324121 PO Box 9264, Des Manes, IA 50306-9204 515-244-9124 FAX: 515-239-1837 Certified Abstract of Driving Record Inquiry Date: 9/7/2012 DL/ID #: 545AGO871(IA) Customer #: 5868786 Name: Salah, Omer Elhaj Class: D ID Status: None Address: 2630 WHISPERING Audit #: 5935755 DL Status: VAL PRAIRIE AVE Issue Date: 04/20/2012 CDL Status: None City/State: IOWA CITY, IA Expiration 10/15/2016 CDL Cert None 522406812 Date: Status: Endorsements: 3 CDL Med None Status: Mailing Address: 2630 WHISPERING Restrictions: NONE Restriction None PRAIRIE AVE Date of Birth: 10/15/1967 Supplement: Mailing City/State: IOWA CITY, IA Sex: M 522406812 History Information Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number 7UR 09/20/2011 .648800 IA Name: Salih, Omer Elhaj DL/ID: 54SAGO871 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: +""• X7'%'4 9/7/2012 IOWA '.' D.O.T.: . :g" ' COKV-V ae� yf S= Office of Driver Services q9 Iowa Department of Transportation Name: Salah, Omer Elhaj DL/ID: 54SAGO871