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CITY OF IOWA CITY
410 East Washington Street
Iowa City. Iowa 52240-1826
(319) 356-5040
(3 19) 356-5497 FAX
Authorization Number \a—
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
(Office Use Only)
1. Name �,�q 1;2 14h M�
2. Mailing Address V/- t l
3. Telephone: Home �T� 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? /U n
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? z), _
Tyne of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? '-/0
Type of offense Where When
8. Has your drivel's license or chauffeurs license been suspended or revoked in the last five years?
Tvoe 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)
iann.�a�oad9 06/2012
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
G/ 4 I understand that if I falsely answer any questions in this applications that this
applica ion may bB denied. 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 ./u 0 h d ^ c Date rti !� — 1:`7_ — � 2 --
STATE
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by A'10�nmm.ci ,CCAs.: --F On this
S
C_ b- .
o °t
Number
Commis ton 159791
M Commission ExpI
3 7 RO -S
/6- day of
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).
�
Sign ture o oli hief oo de� Date
a=Qy'R ZZA�� \a ao t
Signature of City Clerk or designee 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
deMt drivbadgeapp2010.do 06/2012
Sep, 25. 20121, 10;16
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RP r,AiVAA TImP91 R%pn. 14...,7017. 9:4)AM No. 1745
0
Iowa Department of Transportation
Il 0 Office of Driver Services (fall Free) BDO-532-1121
PO Box 9204, Des Moines, lA 50306-9204 515-244-9124
FAX: 515-239-11337
Certified Abstract of Driving Record
Inquiry Date:
9/7/2012
DL/ID #:
467AF4945 (IA)
Name:
Kharif, Mohammed Adam
Class:
D
Address:
102 66TH AVE SW,APT 5
Audit #:
5619729
Issue Date:
11/08/2011
City/State:
' CEDAR RAPIDS, IA
Expiration Date:
08/25/2015
524045365
Endorsements: 3
Mailing Address: 102 66TH AVE SW APT 5 Restrictions: NONE
Date of Birth: 8/25/1980
Mailing City/State: CEDAR RAPIDS, IA Sex: M
524045365
History Information
CLEAR DRIVING RECORD
Name: Kharif, Mohammed Adam DL/ID: 467AF4945
Customer #:
5753604
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status: None
Restriction None
Supplement:
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:
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9/7/2012
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Office of Driver Services
Iowa Department of Transportation
Name: Kharif, Mohammed Adam DL/ID: 467AF4945
I
IOWA
112 66TH AVE S W
CEDAR RAPIDS, fA AP PT S
Yow 71•wqe
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