HomeMy WebLinkAbout13-207 Authorization Number /3 ,o7
I r 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
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lel A-4)I A h Last AIN I 6I_I aHyl (1/
1. Name ,,(t,� rt Iv' •-
2. Mailing Address ) ,.t 0 q pb,u/r)
3. Telephone: Home Other: red' (2.k ) . 3 -6 (,k-7 I.S--
4. Prior experience in transportation of passengers:
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5. Have you ever been convicted of any misdemeanors and/or feloni
Type of offense Where 1111811111"1en
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?
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?
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)
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)
derkftaxidrivbadg 03/2013
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I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
ta-7 4 A n t{$,.� . 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 C v Date Cr/ I 21/S
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by Va.,S I f IA. Ati‘r.Ql'I.(ak vkp►1 . On this )a--- day of
awe t Notary Public(r1 and for the Sta e o Iowa
• • kW Commission Expos
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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Signat of Polii• o ief 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.
/r4. -f-{-04.4.------ 7—/,2-— / 7
Signatur'-of 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
clerk/taxidrivbadgeapp2010.doc 03/2013
J
*IIIowa Department of Transportation
I Office of Driver Services (Toll Free)800-532-1121
PO Box 9204,Des Moines,IA 503O0-92174 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 9/12/2013 DL/ID It: 274AD4829 (IA) Customer 7t: 5437579
Name: Abdeirahman,Yasir H Class: D ID Status: None
Address: 1409 PLUM ST Audit it: 5452048 DL Status: EXP
Issue Date: 08/18/2011 CDL Status: None
City/State: IOWA CITY, IA Expiration 07/05/2013 CDL Cert None
522402121 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 1409 PLUM ST Restrictions: Corrective Lenses Restriction None
Date of Birth: 7/5/1961 Supplement:
Mailing City/State: IOWA CITY, IA Sex: M
522402121
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
10/20/2012 02/15/2013 '593 Speed rJohnson IA
01/13/2013 '02/04/2013 M70 ,Improper Passing ',Johnson +IA
Accidents-Accident involvement indicated does NOT mean the individual was at fault or given a citation.
Accident Date Case Number JUR
10/20/2012 __... 709082 IA
Name: Abdelrahman,Yasir H DL/ID: 274AD4829
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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. Sep. 7. 2013 4.:49PM . CDiv of Criminal Investigation, NNo. 5130 pP. 3/3
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Received Time Aug. 29. 2013 4:30PM„No. 4359 r •