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Home My WebLink About13-229 Authorization Number i j 1 (Office Use Only) Am=NW CITY OF IOWA CITY APPLICATION FOR TAXI DRIVER (Police Department review must be made 410 East Washington Street between 8 a.m.to 3 p.m., Monday—Friday.) Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX First r Middle--- Last 1. Name +��r �� G A 2. Mailing Address 2.6- 0 g ,- (._itt- t o �� - cU 1 �j 2- L Lt 3. Telephone: Home . 15$ l 0\ 3 c 2 Other: 4. Prior experience in transportation of passengers: r> y c— .r 5 • R3 yAdl.Z=003IN `C 5. Have you ever been convicted of any misdemeanors and/or felonies in this State orelisar*rn .`�;� 1. 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? U Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? '> Type of offe pse Where When -1 f� '7 v°p x\5,----c\ l\!�C �t � (gc. 2 ` Sp / t / 2_011 L<< py cif o/ 2<-3cb' 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 0 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) / 0 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). (OVER FOR REQUIRED SIGNATURE AND NOTARY) cierkRaxidrivbadg 03/2013 ; I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number Z SS n D 3 cl I ti- . 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 2 ��/ *************,t****k*******************t.*********:t******************************w*********************k*k**kith******,*********x*****,t*********i** STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by _wA,; ( jc.k,� A/ki,,` . On this oV L.!-r--4. day of /� WENDY S.MAYER Notary Public in d for the State of wa Wllnl /Nu r 20 ***********************.***Lr***** ********************************************************************************************************* 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). ignatur o '/2x7/3f Police Chief 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. r-C A/j (i/0 i /1-21 Signa . e of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width) and 5'/2" (height)and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update • derkttaxidrivbadgeapp2010 doc 03/2013 Sep. 20. 2013, 9:44AM Div of Criminal Investigation No. 8437 P. 1/1 ocy; II. Lvu L.J7 Ir lily viesx oily of lona oily Ivu. 307) I. L Aei,% STATE OF IOWA .0.k; t,,1, Criminal i iistory Record Check • y " •'>49 t"iA` rii Request Form p • 'FI°sur �4` I41-09ff)' ,III Ui• --.04` �r4,rOljr'i' t �M` • DCIAccountNttmbor: app -- (it applicable) To: Iowa Division of Criminal Investigation 14'om: City of Iowa City Support Operations Eureau,I"Floor City Clerk's Office 215E.71h Street 410 B.Washington Street Des Moines,Iowa 50319 (515)725-6066 Iowa City, TA 52240 (515)725.6080 fax phone: 319-356-5041 Fax: 319-356-5497 • I am requesting an Iowa Criminal Histo Record Cheolc on: Last Name(mandatory) ]?lust Name(mmfdatory) Middle Name(recommended) A it l7) s ics. M \ c-*. Tom \-k A. Date of Birth(mandatory)`� Gen��ddeerr(m((m_andatory) yy Social rSecurity Number (recommended) 1 /0 7 / 'el J LJMale ❑D erre 16- 2 L rVo — 6 8 5 7 Waiver Information:Without a signed waiver from the subject of the request,a complete criminal history record may not be releasable,per Code of Iowa,Chapter 692,2,For complete criminal history record information,as allowed bylaw,always obtain a waiver signature from the subject of the request, Waiver Release;I hercbygivc permission forth;about requesting otllclal to conduct en Town criminal hlsloryrccord check witlr Elm Divislon of Ceminel InvestigatIon(DCl). Any arlminel history dela concerning mediae Is maint Ined by the DClmay be released es allowed by law. Waiver Signature; j� Ioowa Criminal History Record Check Results (DCI use only) M of -+ \v, , a search of the provided name and date of blith revealed: • • tp No Iowa Criminal History Record found with DCI ® Iowa Criminal History Record attached,DCI# • DClinitials Received TimerS9,_ 17:I(2013 2: 39PM No, 7976 • Iowa Department of Transportation 413 11 (_)Mice.of Unver Services (Toll Free)800-532-1121 PO Bo. _� Q4 U � Worries, 541:3(.?'... r �t 515-244-9124 PAX:515-239-1837 Certified Abstract of Driving Record Inquiry Date: 8/29/2013 DL/ID #: 255DD3914 (IA) Customer #: 4327702 Name: Amin, Samir Taha Class: D ID Status: None Address: 2608 BARTELT RD Audit#: 5708685 DL Status: VAL APT 1C Issue Date: 12/28/2011 CDL Status: None City/State: IOWA CITY, IA Expiration Date: 01/01/2017 CDL Cert Status: None 522462730 Endorsements: 3 CDL Med Status: None Mailing Address: 2608 BARTELT RD Restrictions: NONE Restriction None APT 1C Supplement: Date of Birth: 1/1/1963 Mailing IOWA CITY, IA Sex: M City/State: 522462730 History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 09/07/2008 10/07/2008 .S93 Speed Johnson IA 01/08/2011 02/11/2011 M14 Fail to Obey Traffic Johnson IA Sign/Signal 09/01/2011 10/02/2011 ,S92 Speed Black Hawk IA Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number JUR 09/06/2008 458497 IA Name:Amin, Samir Taha DL/ID: 255DD3914 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: ars: =,Nab 8/29/2013 • f:' IOWA' �o. O. T. hqn!eitt........e` 4.0 , � Office of Driver Services Iowa Department of Transporation Name:Amin, Samir Taha DL/ID: 255DD3914