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Home My WebLink About12-256CITY OF IOWA CITY 410 East Washington Strcet Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX First 1. Name .1aiA+ Authorization Number /A -025�9 (Office Use Only) APPLICATION FOR TAXI DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday.) 2. Mailing Address 25 4 12,orkel- 12J APT 4A, lotilo61( (A S, 3. Telephone: Home Other: _�IIq- 32 (- C�1 q? - 4. 24. Prior experience in transportation of passengers: 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? N o 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? �, ) o Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? ves e DUT r. n Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? lT c'1 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 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) clack .id,i Cadg 09/2012 /108 AI=23WS I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license numbed Ze1 no la 6cit' o ( I 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 1/ Date /n_26 rt}4F####*4#*#***k*RR4#f#1rtf#fl1Rrt11f#*rt#*####f####F4F+#Y#H#iFF#####*#t*****}f*R***kt*f***k*R***M***4f*44*444*44!444**RMNfi4#RtYff#fYY44#M#Y STATE OF IOWA ) COUNTY OF JOHNSON ) S gibed and swom to before me by z %ne b ��%rt✓ L-'7 �–Si �V� On this ZCo1—day of ��_�(� �u� KELLIE K. TUTTLE o Commission Number221819 .... —mi«d1 ExWes Notary Public in and for the State of Iowa !f#f#%#R#*kk**k***3*%*k%ii*1*R4RiiR3f44i**31431lf*lRl3Rlf#fl11RRf*kfiRf%*#***#%R#*1R#f*##**##*R#**%k***k*%%#%%k***k*#**33*3*3*4*RR331*ii#4i**it*4 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 at re of Polj hie! or designee 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. 24a t, �9ci /f/ - // Ln Signature of City Clerk or designee Taxi cab businesses are required to provide Driver Identification cards. Office Use Only Approved application DCI report State certified driving record Website update Date deddtexi&d dgea,2010.dm 09/2012 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 Address 2 S City/State/Zip r k -u ' — 2 Phone# 3) 9' 1 - 6% 2 Requesting 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) CgSjan a.inefu)ec�i)� Date (if Birth Fecha Nacrmienlo (mandatory) Gender Genero (mandatory) Social Security Number (recommended) (Ou(nou 3 Male []Female Z9 L(' Waiver Signature Firma (If the request is on yourself, please sign. If the request is on someone else, write N/A.) 2 .- Resujl�t�s C� I As of G U V l� a name and date of birth check revealed: &ko record found ❑Record attached, DCI #. DCI initials Receipt Number of requests —\— x $15.00 per last name= Total amount $_ E�) , to Dcl USE ONLY Method ofpayment: ❑cash nn ❑/money order ❑check # �,E Mccasttcr77Card or Visa Cardholder's name \I �� t YS l/� Last 4 digits of MC or Visa L1JG�� DCI initials ---------------------------------------------------------------------------------------------------------------------------------- Credit Card Number # Exp. Date u Iowa Department of Transportation Office of Driver Services (Toll Free) 800-532-1121 F0 Box 9204, Des Moines, IA 50306-9204 515-244-9124 FAX: 515-239-1837 Certified Abstract of Driving Record Inquiry Date: 10/19/2012 DL/ID #: Name: Gasim, Zalnelabdin Bala Class: Address: 2504 BARTELT RD APT 2A Audit #: 06/11/2010 CDL Status: Issue Date: City/State: IOWA CITY, IA 522462714 Expiration 3 CDL Med Status: Date: NONE Restriction Endorsements: Mailing Address: 2504 BARTELT RD APT 2A Restrictions: M Date of Birth: Mailing City/State: IOWA CITY, IA 522462714 Sex: Convictions 408AF2348 (IA) Customer #: 5591494 D ID Status: None 4427653 DL Status: VAL 06/11/2010 CDL Status: None 09/09/2015 CDL Cert Status: None 3 CDL Med Status: None NONE Restriction None 9/9/1983 Supplement: IA M History Information Citation Date Conviction Date ACD Explanation County IUR 04/17/2010 _ _ 05/05/2010 S93 Speed 52 IA 05/02/2010 06/02/2010 M75 Passing School Bus 52 IA 10/22/2010 12/05/2010 S92 Speed 52 IA Accidents - Accident involvement Indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number IUR 04/17/2010 _ 570176 IA 11/16/2011 660394 IA Name: Gasim, Zalnelabdin Bala DL/ID: 40SAF2348 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: ' pFHIC(F~"'o s 1S@•: • od, �� i o; str3 IOWA 4'g °ate D. 0. T. lie ° n" OBIIIEP Name: Gasim, Zalnelabdin Bala DL/ID: 40SAF2348 10/19/2012 Office of Driver Services Iowa Department of Transportation