HomeMy WebLinkAbout13-208 Authorization Number /1) — a-D
1 (Office Use Only)
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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
FirstMiddle Lastk)
1. Name )/ )t fest,
2. Mailing Address �SoL� lL �, ff )- C-
3. Telephone: Home �� $ '(� ,p/11Ci Other: rr
4. Prior experience in transportation of passengers: �< l l�vti CC_
2eCat ( 4� yeeaD-
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vtM s rowNw
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or "0'_"7r"O'�
Type of offense Where
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? )12_.S
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? filiof,
Type
Type of offense Where When
1
9. Have you ever applied tae an Iowa 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)
Clerkltaxidrivbadg 03/2013
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number "
4 Z A l y . 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)
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Signature of Applicant , �_. Date / (6 G'7 I3
a-Jr',
-or
STATE OF IOWA
COUNTY OF JOHNSON )
Subscribed and sworn to before me by (h.p_ty4.'Q44) KIA,R rJ,leS . On this 1 1 -tU day of
% aIota "ublicd and for the State .0 Iowa
• Mfg Mr�r
aims
*********************** *****************************************************************************************************
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).
4 I CZ %2/ 5-1?-13
Signa re of P. c4PChief 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.
.7t 7(-1 • 51e44/1.Y Lt/i /rb
Signa_ re 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
clerk/taxidrivbadgeapp2010.doc 03/2013
'i Sep. 11' 2013 ,13:46PM. ' Div of Criminal Investigation ' 1,;' No. 7122. 'P. 1 , ;.( '
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Received- Time Aug. 14. 2013 4: 28PMyNo . 36174<2r) • .. -
(IN Iowa Department of Transportation
c83 Office of Dever Services ad!A..)80G-532-1121
PO Boat 9204,Des Moines. IA 50306-9204 515244-9124
FAX 515239-1837
Certified Abstract of Driving Record
Inquiry Date: 9/10/2013 DL/ID#: 542AG9038(IA) Customer#: 5863128
Name: Khames, Mohamed Class: D ID Status: None
Address: 2540 BARTELT RD Audit#: 7227307 DL Status: VAL
APT 2C
Issue Date: 08/09/2013 CDL Status: None
City/State: IOWA CITY,IA Expiration Date: 01/06/2018 CDL Cert Status: None
522462723
Endorsements: 3 CDL Med Status: None
Mailing Address: 2540 BARTELT RD Restrictions: NONE Restriction None
APT 2C Supplement:
Date of Birth: 1/6/1974
Mailing IOWA CITY, IA Sex: M
City/State: 522462723
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
01/17/2012 03/27/2012 592 .Speed Johnson IA
02/24/2012 05/04/2012 S93 ,Speed Johnson IA
11/29/2012 03/28/2013 592 Speed Johnson IA
Name: Khames, Mohamed DL/ID:542AG9038
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:
jegf 9/10/2013
..fs,%i
t IOWA
D. 0. ...;
.. =elope., clegeritiviA
Office of Driver Services
Iowa Department of Transporation
Name: Khames, Mohamed DL/ID: 542AG9038