HomeMy WebLinkAbout13-204 Authorization Number / — at-)4
r 1Office 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 `(�_LL We-.1- SL(, '71-
(319) 356-5497 FAX
First? Middle _Lastn
1. Name j).. /A/CV/4M,4EP / L�/ C f3ti
2. Mailing Address Af 1/t1 2c, I H c'//d a j 12 cI (o} f Vi `/e= f A 1 1 2 b 22141
3. Telephone: Home J Other: 1/ 5 -- 2/ 3 - 6 el. -�
4. Prior experience in transportation of passengers: /t/<7y e
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /v-
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- `
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? N' ----
Type
Type of offense Where When
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)
derk/taxidrivbadg 03/2013
hereby certify that I hay ssued to me by the Iowa Department of Transportation a valid Chauffeur's license number
c L, 4,10 ci L( . 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 provisos of Title 5, Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public)
1' .____
•
Signature of Applicant Date �('_ �G ,, I S
, /
STATE OF IOWA )
COUNTY OF JOHNSON ) 1
ubd scrib and sworn to before me by cj e2Cta,k Ili- -8l,t rr . On this 104- day of
w_ e,f . o 11� I- _e
u ac KFI I IF K Tl1TTl F Notary Public in and for the State of Iowa
'
Commission Plumber 221819
i= My i� n it s
***.*.******** *****.************* ************ t��G ***************************************************************************
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).
70,1*-4� 7-10-0
Sign re of P., o hie 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.
Si nate of CityClerk or designee g g 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
derWlaxidrivbadgeapp2O10.doc 03/2013
Sep. 5. 2013 9: 43AM Div of Criminal Investigation No. 6164 P. 19
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Received Time Aug. 28. 2013 1 :20PM No. 5437 , i)
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fIowa Department of Transportation
Office of Driver Services (Tal Free)8a0-532-1121Pt)Box 9204,Des Moines,IA 50306-9204 515-244-9124
141111. FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 8/30/2013 DL/ID#: 705AI0514 (IA) Customer#: 6098518
Name: Burbur, Seedahmed Class: D ID Status: VAL
Mohammed Sidahmed
Address: 888 BOSTON WAY APT Audit#: 7084480 DL Status: VAL
6 Issue Date: 06/28/2013 CDL Status: None
City/State: CORALVILLE, IA Expiration 10/28/2018 CDL Cert None
522413126 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 888 BOSTON WAY APT Restrictions: Corrective Lenses Restriction None
6 Date of Birth: 10/28/1976 Supplement:
Mailing City/State: CORALVILLE,IA Sex: M
522413126
History Information
CLEAR DRIVING RECORD
Name: Burbur,Seedahmed Mohammed Sidahmed DL/ID: 705A]0514
Pursuant to Iowa Code §321.10, I, Klm 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:
`r..'''if 8744% 8/30/2013
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+11 Office of Driver Services
Ny Iowa Dpaartmet of Transportation
Name: Burbur,Seedahmed Mohammed Sidahmed DL/ID: 705A]0514