HomeMy WebLinkAbout12-239CITY OF IOWA CITY
410 East Washington Street
Iowa Ci 2240-1826
(Iffj9) 356040__ 61112- ue5
(319) 356-5497 FAX
1. Name
2. Mailing
Authorization Number / � — -'�3 /
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
3. Telephone: Home N O Z— 2 O a --I P Z
4. Prior experience in transportation of passengers:
Q lM _+ c, v i r -e A 1V\ r w -
Other:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
Where
When
ON
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? i p
Type of Offense
Where
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense
Where
When
When
8. Has your driver's license or chauffeur's 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 ysing 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 R—EVIEVv—
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)
derMmiddvbadg 06/2012
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I J�eby c fy ha'e issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
a . I understand that if I falsely answer any questions in this application, that thN
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 th 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 Date i 0 — 2
STATE OF IOWA )
COUNTY OF JOHNSON I
bs rib d and swfl to
before me by S ha),)1 Y I C1GLrl rA-C-d On this day of
{1
�KEL1�,� /� Co� Notary Public in and for the State of Iowa
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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).
�Yp
Signat re of Police Chief or designee
Signaftife of City Clerk or designee
/0-3-/ Z --
Date
iD-3 - 1.;-71
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
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Oct: 3, 201) 11:23AMi
Div of Criminal Investigation
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Received Time Sep, 25, 2012 10:56AM No, 3993
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Page 1 of 1
Iowa Department of Transportation
Office of Driver Services (Toil Free) 811-532-1121
PO B€rac 9204, Des Moines, Nk 5U3€tf} 92i}4 5115-244-9124
ILA FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
9/11/2012
Name:
Sidahmed, Shakir
CDL Med
Mohamed
Address:
2509 BARTELT RD APT
Restriction
1D
City/State:
IOWA CITY, IA
522462715
DL/ID #: 532AG5413 (IA)
Class: D
Audit #: 5450123
Issue Date: 08/17/2011
Expiration 04/20/2016
Date:
Endorsements: 3
Mailing Address: 2509 BARTELT RD APT Restrictions: NONE
1D Date of Birth: 4/20/1957
Mailing City/State: IOWA CITY, IA Sex: M
522462715
History Information
CLEAR DRIVING RECORD
Name: Sidahmed, Shakir Mohamed DL/ID: 532AGS413
Customer #: 5846338
ID Status: None
DL Status: VAL
CDL Status: None
CDL Cert
None
Status:
CDL Med
None
Status:
Restriction
None
Supplement:
Pursuant to Iowa Code 4321.10, 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:
'•:;�'/��y4 9/11/2012
IOWA *
). 0. T.I.
r'......5 Office of Driver Services
„ORIYER,= Iowa Department of Transportation
Name: Sidahmed, Shakir Mohamed DLM: 532AGS413
httD://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 9/11/2012