HomeMy WebLinkAbout12-280�f -4
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
Authorization Number /,;- - )-SD
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
(Office Use Only)
(319) 356-5040
(3 19) 356-5497 FAX
First Middle Last
1. Name O Y" e r n s rv\UrN Sam A\
2. Mailing Address Z,6_00' 4,r -If- 8 O a YJ _" -? �
T
3. Telephone: Home 3 e?, , 2? ((i Other:
4. Prior experience in transportation of passengers: /✓o
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? IVO
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?A16
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? /✓U
Type of offense Where When
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? /1/6
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)
/V 6
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE C EF REVIE
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)
d.rMe &Id badg 09/2012
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license num+aer
�L R?AF 35 66 . 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 1 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 Applicantc)VA--r- sad0%-\ Datefx/////y
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by orn�g � Safe, On this tl day of
Notary 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).
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.
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
/'1- //- i ---
Date
deNhexidnWadgeapp=0,d 09/2012
AC
Iowa Department of Transportation
Office of Driver Services (Toll Free) 8OM32-1121
FO Box 9204, Des Moines, IA 50306-9204 515-244-9124
OFAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
12/11/2012
DL/ID #:
483AF3560 (IA)
Name:
Saleh, Omer Osman
Class:
D
Address:
2606 BARTELT RD APT
Audit #:
5894633
CDL Med
2C
Issue Date:
03/31/2012
City/State:
IOWA CITY, IA
Expiration
01/01/2016
522462729
Date:
Endorsements:
3
Mailing Address:
2606 BARTELT RD APT
Restrictions:
NONE
2C
Date of Birth:
1/1/1979
Mailing City/State: IOWA CIN, IA
Sex:
M
522462729
History Information
Customer #:
5775887
ID Status:
VAL
OL Status:
VAL
CDL Status:
None
CDL Cert
None
Status:
Iowa Department of Transportation
CDL Med
None
Status:
Restriction
None
Supplement:
Accidents - Accident involvement Indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number 3UR
06/03/2012 688441 IA
Name: Saleh, Omer Osman DL/ID: 483AF3560
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 wltness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa
this date:
:.. �4
12/11/2012
IOWA .
D. 0. 1.:
7p '••••'' Ste=
Office of Driver Services
Iowa Department of Transportation
Name: Saleh, Omer Osman DL/ID: 483AF3560
c
Nov. 6.
2012
11:54AM
Div
of Criminal Investigation
Od.31.
2012
1:34PM
City
Clerk - City of Iowa City
No.2950 P. 5/5
No, 2977 P. 2
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