HomeMy WebLinkAbout13-221 Authorization Number J — ,3`
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APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
410 East 1,Vashington Street between 8 a.m.to 3 p.m., Monday-Friday.)
Iowa City, Iowa 52240-1826
(319) 356-S040
(319) 356-5497 FAX
First Acl • I Middle , i_ n Last 051,461 ) �
1. Name I �d of cuii G'1 V!
2. Mailing Address I( 1n/E_'' t-CJ'4j- , wc-4 e _ijf1 323. Telephone: Home19 3 >> - b 4 Other:
4. Priorr experience in transp.rtation of passengers: p r tri.
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5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? NO
Type of offense Where When
6. Have you be cTvicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? C
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? yds
Type of offense Where When
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8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /\/ c)
Type of offense Where When
9. Have you ever applied to be an lora 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).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
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I her byCcertify tat I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
(i // , . I understand that if I falsely answer any questions in this application, that this
application may e denied. I uerstand 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 CACi i ..C -7-411 rr\,ti Date 1 247 / /3
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STATE OF IOWA )
COUNTY OF JOHNSON )
sribe and syvorn to before me by ,��, / OSi`Y2c_ ,'l . On this S`'Le� day of
7)7:6-4 t L? r ,-' c_,/
''/.t KELLIE K.TUTTLE Notary Public in and for the State of Iowa
fr Commission umoer t11O 1a
ii
•f1ttak1y cjjoom sision x(jp/fifes
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).
77, - - 23 J.3
Signature f 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.
(_,a 4.-e-,172.-- - 1/2 ; c t/.15//
Signature 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 1/2"
(height) and prominently displayed to all passengers.
************************************************************************************************************************************************
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Geri axidrivbadgeapp2010.doc 03/2013
Jul. 23. 2013' 12: 15PM .(,Div of Criminal IInvie stigation,. NNo. 0089 PP. 1/1 •
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' Iowa Department of Transportation
, Office of Driver Services (Toll Free)800-532-1121
PO Box 9204,Des Manes,IA 503135-9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 9/25/2013 DL/ID#: 249AD2618 (IA) Customer#: 5410029
Name: Osman,Adil M Class: D ID Status: None
Address: 102 WESTSIDE DR Audit#: 6455092 DL Status: VAL
Issue Date: 11/08/2012 CDL Status: None
City/State: IOWA CITY,IA 522464356 Expiration Date: 10/26/2015 CDL Cert Status: None
Endorsements: 3 CDL Med Status: None
Mailing Address: 102 WESTSIDE DR Restrictions: NONE Restriction None
Date of Birth: 10/26/1969 Supplement:
Mailing City/State: IOWA CITY,IA 522464356 Sex: M
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
10/14/2009 11/06/2009 M14 trail to Obey Traffic Sign/Signal Johnson IA
07/27/2010 10/01/2010 592 ;Speed _ __ Johnson IA
10/29/2011 01/30/2012 M14 Fail to Obey Traffic Sign/Signal Johnson IA
Accidents-Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
05/01/2009 505835 IA
Name: Osman,Adll M DL/ID: 249AD2618
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:
At. Z�%f�ir 9/25/2013
I' IOWA %f;
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%i,.D. O. T...411 1�irrei e_ Iowa Office
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Departmr terovlicesnsportation
Name: Osman,Adll M DL/ID: 249AD2618