HomeMy WebLinkAbout13-211 �\ \
- r Authorization Number �
(Office Use Only)
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
n Irst Middle Last
1. Name A/ ► °� 5�2 _ YAr. V\S (��'1fJot L1
2. Mailing Address 2__l 0 G iS 7 , 1,Q 2-
3. Telephone: Home L ` ?--q 3d 00\3 Other:
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this Stat giallrEN
woo scow
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? N., 0
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? ,t)
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? r.
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)
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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)
clerk/axidrivbadg 03/2013
I herebyerti th I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
d �' 7 . I understand that if I falsely answer any questions in this application, that this
appkuation may be denied. I ur derstand 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 I f t 7
STATE OF IOWA
COUNTY OF JOHNSON )
•
Subscribed and sworn to before me by 1V+ib-�a-Sp�, � F e.1 Lk CLL . On this / A day of
otary Public ing:nd for e State of lo ;a
fir ��aiort�,r�on FSM
i�.•. :rn
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).
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Sign ture o Police Aief 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.
// -f--ec,t�v- A • -eet i/ 7— / l ' C!/
Sign ture of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width) and 51/2"
(height)and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
•
cierkQtaxidrivbadgeapp2010.doc 03/2013
• Aug. 21. 2013 3: 54PM Div of Criminal Investigation No. 3388 P. 1
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Received Time Aug, 19. 2013 11 : 34AM4tN9a2939 QO •
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Iowa Department of Transportation
4:83 i Office of Driver Services (fill Free)800-532-1121
PO Bax 9204,Des Milnes,IA 50306 9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 9/17/2013 DL/ID #: 504AG8847 (IA) Customer#: 5804331
Name: Efreiwan, Motasem Class: D ID Status: None
Address: 210 6TH ST APT 83 Audit#: 6730276 DL Status: VAL
Issue Date: 02/28/2013 CDL Status: None
City/State: CORALVILLE, IA Expiration 09/30/2014 CDL Cert None
522412528 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 210 6TH ST APT 83 Restrictions: NONE Restriction None
Date of Birth: 12/30/1986 Supplement:
Mailing City/State: CORALVILLE, IA Sex: M
522412528
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
09/17/2011 j09/29/2011 4592 ;Speed Johnson IA
02/22/2013 :04/04/2013 I Tlmproper Registration Johnson IIA
Name: Efreiwan, Motasem DL/ID: 504AG8847
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:
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cit... C ��GNewt, 9/17/2013
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,,'1�C 81Rg of Driver Services
, 0YEIowa DpartmetofTansportation
Name: Efreiwan, Motasem DL/ID: 504AG8847