HomeMy WebLinkAbout12-247Authorization Number / � —M
(Office Use Only)
APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
410 East Washington street between 8 a.m. to 3 p.m., Monday — Friday.)
Iowa City,_ wa 52.240-1826
0356 50411��'i 112
(319) 356-5497 FAX
FirstMiddl FF + Last
K a
1. Name A11vA MO ctw eA C) a i l rv►
2. Mailing Address
3. Telephone: Home ,SSS, 17 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? A/C
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? Ale,
Tvpe of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? 4/O
Tempe of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Ale
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 ST
DRIVING REC D -MUST ACCOMPANY THIS APPLICATION FOR LICE 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)
dMm iddvbadg 09/2012
I hereby certify that 1 have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
,: 6�3 �7 7. Sod � . I understand that if I falsely answer any questions in this application, that this
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 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 Date /0
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STATE OF IOWA )
COUNTY OF JOHNSON ) n
S pribe d sworn to before me by A�.fY�o SitisI Y1L On this day of
a r 2c� I Z
KELLIEK.TUTTLE _,_ KP L_C(-P
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).
Signa re of If hief or designee
7/a
Date
YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY
CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org.
Ad44aZ–�) 7�1
Sign a of City Clerk or desig— n�
Taxi cab businesses are required to provide Driver Identification cards.
Date
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
den mddwadgeaW2010.d« 09/2012
Oct. 15.
Oct. 5.
2012 2:37PM
2012 11:54AM
Div of Criminal Investigation
City Clerk — City of Iowa City
( gHmba$.J lstory Record C ech:
RequestForm
No. 9433 P. 1
No. 2899 P. 2
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Iowa Department of Transportation
u Office of Driver Services (Toll Free) OM -532-1121
PO Box 9204, Des Moines, IA 50306-9204 515-244-9124
FAX: 515-2394837
Inquiry Date:
10/9/2012
Name:
Jasim, Ahmad Mohamed
Address:
2401 HIGHWAY 6 E APT
CDL Status:
2213
City/State: IOWA CITY, IA 522406782
Mailing Address: 2401 HIGHWAY 6 EAPT
2213
Mailing City/State: IOWA CITY, IA 522406782
Certified Abstract of Driving Record
DL/ID #: 262DD7527 (IA)
Class: D
Audit #: 5815001
Issue Date: 02/22/2012
Expiration Date: 08/15/2016
Endorsements: 3
Restrictions: NONE
Date of Birth: 8/15/1965
Sex: M
History Information
CLEAR DRIVING RECORD
Name: Jasim, Ahmad Mohamed DL/ID: 262DD7527
Customer #:
4644653
ID Status:
EXP
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:
Name: Jasim, Ahmad Mohamed DL/ID: 262DD7527
10/9/2012
IOWA o4sE
D. 0. T...'
f ....... Sr
Office of Driver Services
�a Bal�`
Iowa Department of Transportation
Name: Jasim, Ahmad Mohamed DL/ID: 262DD7527