HomeMy WebLinkAbout12-225,r
f
CITY OF IOWA CITY
410 East Washington Street
Iowa CUty, Iowa 52240-1226
..( 19) 3S6-504 i -'t -i 9 i
(319) 356-5497 FAX
First
1. Name -
2. Mailing Address 7
3. Telephone: Home s�/(/-
4. Prior experience in transportation of passengers:
Authorization Number I/ d —a 6'
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
Other.
Last
(Office Use Only)
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? �' C
Type of offense Where When
6. Have you ben 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? 6�
Tvpe of offense Where When
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? /V !i
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)
A)o
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)
dedw 4iwedg 06/2012
3/✓gc�S'76
1 h$rbby ce ify th I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
1 7 � . I understand that if I falsely answer any questions in this application, f6at this
aap li�ion ma>�enied. I understand that W 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 ti�1r es ath- visions of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public)
Signature of Applicant , Date - ,
YY#+4#H+YH+Y#44i4+iFF+#H#H###!##4H4#Hf11ff #f1fffffHYHIfHHffY#HfIHHH+f#ff+HH+Hf#1H+HH4H+4YHfi+##HH+HH#'#1`lHMH1HHYH
STATE OF IOWA )
COUNTY OF JOHNSON ) I / p j 1
S bscribed d swop to before me by I�Qj1 :S)0 YVjLGL On this -1 / day of
KELUE K. TUTTLE
i �,ommissron Num er 22187 otary 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).
na uri
OW Police Chief or designee
Signature of City Clerk or designee
/Z
Date
g .2,/= i -I-
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.
1tRRH1flHRRMRHlffffllHf#-kf#fHH##itH##Hi#44+H#4+FH+#H###+#H#H#HHRH+4H+H###+H#H+HH##RRR##i###RRfHH4f #fRRHRf #fHfRHffM
Office Use Only
Approved application
DCI report
State certified driving record
Website update
derk/Iaxidriv da aW2010 d 06/2012
Iowa Department of Transportation
Office of Driver Services (Toll Free) 800-532-1121
�U PO Box 9204, Des Moines, IA 50306-9204 515-244-9124
iFAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
8/31/2012
DL/ID #:
131AC5876 (IA)
Name:
Slama, Kamel Gassmelseed
Class:
D
Address:
948 23RD AVENUE PL APT 5
Audit #:
3974450
Restriction
None
Issue Date:
12/29/2009
City/State:
CORALVILLE, IA 522411277
Expiration Date:
08/02/2012
S92
Speed
Endorsements:
3
Mailing Address:
948 23RD AVENUE PL APT 5
Restrictions:
NONE
Date of Birth:
8/2/1966
Mailing City/State:
CORALVILLE, IA 522411277
Sex:
M
History Information
convictions
Customer #:
5239074
ID Status:
VAL
DL Status:
VAL
CDL Status:
None
CDL Cert status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Speed (10 mph & under in 35-55 mph zone)
Citation Date
Conviction Date
ACD
Explanation
County
IUR
03/20/2008
05/29/2008
S92
Speed (10 mph & under in 35-55 mph zone)
16
IA
03/15/2009
05/12/2009
S92
Speed (10 mph & under in 35-55 mph zone)
52
IA
07/05/2011
08/22/2011
S92
Speed
52
IA
Name: Slama, Kamel Gassmelseed DL/ID: 131AC5876
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:
'- •:!!j'y
8/31/2012
IOWA
r
F5s;
10. T.W ,
`OAIYEHS�Q
Office of Driver Services
Iowa Department of Transportation
Name: Slama, camel Gassmelseed DL/ID: 131AC5876
Sep. 12. 201210; 34AM
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Div of Criminal Investigation No. 3767 P. �3
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Iowa Crimiw9l MsiokW Reeazd ChecS��esr>IXt� . 1pe,,,,,an�
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As of � � /a ` � �, a search of the provided name Aird dgto of bi>.�tha'cvesled: 7
NO rblva Crilziinaliistory S2ecord found WithDCl
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� Zowa CiimfttalSl'istoxyRecord attached, DCI#
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3eceived Time Aug -31, 2012 2;22PM No.2568