HomeMy WebLinkAbout13-203 Authorization Number U
� — 1 (Office Use Only)
CITY OF IOWA CITY APPLICATION FOR TAXI DRIVER
(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 J
(319) 356-5040 CP<(_ ")ed. $�a�/ /3
(319) 356-5497 FAX
First M ddle L st
1. Name t< ovvAvAcj �1 C( 5 ( V 1
2. Mailing Address j 17. I A-5)A S+ i C�w q C;4-Ai ,'tLt -2-yo
3. Telephone: Home 3 l q - 3/ ) — 0 4 y" Other:
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4. Prior experience in transportation of passengers: '.n10V/ k Y\op W;-+k J O \./AJ( v"\ 1 GIX \ Cri 1,
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5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elilnititielm'�� d' ,
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? j 7l: 5-<< Ger) 'J,n� r'eGo Id
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? W 0
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)
derk/laxidrivbadg 03/2013
,
I hereby certi that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number'.
0' C')//: F D 3 I . 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 6i{ —/0 — i 3
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by tkb\e‘cL ti,ktrO A.), a SItia4; f . On this j p t\d‘s. day of
\,-1VVi ENDY&SIRniel Notary Public in for the State of Iowa 52-J\---
. C°F..... 11:31116.11
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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).
Signa re of Po Thief 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.
Signet re of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8'/2" (width) and 5 V2"
(height)and prominently displayed to all passengers.
************************************************************************************************************************************************
Office Use Only
Approved application
DCI report
State certified driving record
Website update
c;c,''taxithivbaddeapp201 D doc 031,
Aug. 28. 2013 3: 00PN>ti Div of Criminal Investigation No. 5455 P. 1/1
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Received Time Aug. 21. 2013 3: 34PM No. 3374 •�_,
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Iowa Department of Transportation
Office of tilrhter Services (Toll Free)800-532.1121
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FO Box 0204,lifts Moines,w 503(16-9204 515-244-9124
F,Ut 515.23M837
Certified Abstract of Driving Record
Inquiry Date: 7/31/2013 DL/ID#: 450AF6378 (IA) Customer#: 5729103
Name: Sharif, Mohamed Ali Class: D ID Status: None
Address: 1121 ASH ST Audit#: 6115230 DL Status: VAL
Issue Date: 07/11/2012 CDL Status: None
City/State: IOWA CITY, IA Expiration Date: 08/17/2015 CDL Cert Status: None
52240
Endorsements: 2 CDL Med Status: None
Mailing Address: 1121 ASH ST Restrictions: NONE Restriction None \
Supplement:
Date of Birth: 8/17/1978
Mailing IOWA CITY, IA Sex: M
City/State: 52240
History Information
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Convictions
Citation Date Conviction Date ACD Explanation County ]UR
11/20/2010 02/15/2011 M14 Fail to Obey Traffic Johnson IA
Sign/Signal
05/11/2012 08/14/2012 M70 Improper Passing Johnson IA
Name:Sharif, Mohamed Ali DL/ID: 450AF6378
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:
Jr' OR k4i 7/31/2013 .
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