HomeMy WebLinkAbout13-217 Authorization Number /3—,-V17
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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, Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
First Middle Last
1. Name cozy- M Ali j / Iv1
2. Mailing Address_ 7, 7 (�✓��Srl � A-1- ? S j�
3. Telephone: Home � Q 3 S I •I 7.5 Other: '3 ` C Lf "7/ 3(fi
4. Prior experience in transportation of passengers:
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5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elc&lMwllA.�}�y brwlr►J
Type of offense Where 14/hen _..i
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? 1\1 [
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years?
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? y o
Type of offense Where When
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9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
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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)
cleri taxidrivbadg 03/2013
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
yo A( t/-1k4 . 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 pc,! 24):3
STATE OF IOWA
COUNTY OF JOHNSON )
Subscribed and sworn to before me by citA.D.r . �js rclCous. . On this c20 day of
liCcoirTZ.ForrOUR Notary Public in for the State of I a
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).
Signature of tic:, hieor 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.
7/ 41/1.--/
Signatur f City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 81/2" (width)and 51/2"
(height)and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report _
State certified driving record
Website update
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UerWlaxidrivbadgeapp2010.doc 03/2013
Sep. 14. 2013 3: 30PM Div of Criminal Investigation No, 7511 P. 2/6
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Received Time Sep. 10. 2013 2:03PM No. 5531
fillIowa Department of Transportation
Office of Driver Services (Toll Free)800-532-1121
411. PO Box 9204,Des Moines,IA 50306-9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 9/10/2013 DL/ID #: 240AD9724 (IA) Customer#: 5389467
Name: Ibrahim, Omar Ibrahim Class: D ID Status: None
Mohamed
Address: 707 WESTGATE ST Audit#: 6806770 DL Status: VAL
Issue Date: 03/26/2013 CDL Status: None
City/State: IOWA CITY, IA Expiration 10/10/2014 CDL Cell None
522464638 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 707 WESTGATE ST Restrictions: NONE Restriction None
Date of Birth: 10/10/1975 Supplement:
Mailing City/State: IOWA CITY, IA Sex: M
522464638
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
T]ohnson _
04/02/2010 05/14/2010 N83 Improper Start_ _ __ tIA
10/23/2011 12/05/2011 [414 'Fall to Obey Traffic Sign/Signal Johnson 'IA
07/14/2013 ,08/07/2013 ;S93 Speed ',Johnson SIA
Accidents -Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
07/14/2013 1748678 {IA i
Sanctions
Type Effective End ACD Explanation Occurrence JUR JUR
Suspended 103/13/2012 103/27/2012 D53 Non-Payment of Iowa Fine hIA ;IA 1 t
Name: Ibrahim,Omar Ibrahim Mohamed DL/ID: 240AD9724
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:
9/10/2013
Office of Driver Services
Iowa Department of Transportation
Name: Ibrahim, Omar Ibrahim Mohamed DL/ID: 240AD9724