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HomeMy WebLinkAbout13-196 Authorization Number / 5 - l 9 ofr,1 r 1 (Office Use Only) VIII IN ft. aid=iiunir 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 C'ty. Iowa 52240-I826I C(3f9�356-5040i ) I/y. (319) 356-5497 FAX First Middle Last 1. Name ) (7; y'}i( ��I11 r N<( (_ : )(4.1VtLi 2. Mailing Address Q. Z 1--;(,N - k ?'C -='K \\7 3. Telephone: Home ? cl --2-;t� — \{\.'r ! Other: 4. Prior experience in transportation of passengers: 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? 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? Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? Type of offense Where When 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? Air 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-CHtErREVIEW You must apply for an individual Department of Criminal Investigation Report (form available upon request) The re- port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli- cation. (OVER FOR REQUIRED SIGNATURE AND NOTARY) Lderktlaxidnvbadg 09/2012 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license numbe . 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 \im ► '�'' `)1i v\ `1L1 DateAi. �� ctui ct\A 4 O 'C�u v\ — 0\_3 STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by ,\\J3 ��'����� fi1�� Q STngv` On this day of -1131,Li- Not P blic in and for the State-of Iowa 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). 1//7 , 1inatu ofe Chief or designee Date 99 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. 31� y� K • 1`C 3 - / 3 Signature of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Office Use Only Approved application DCI report State certified driving record _ Website update Gerk/taxidrivbadgeapp2010.doc 09/2012 Iowa Department of Transportation $r Office of Driver Services (Toil Free)8M-532-1121 W PO Box 9204,Des Moines,IA 50306-9204 515-244-9124 FAX:515-239-1837 Certified Abstract of Driving Record Inquiry Date: 8/22/2013 DL/ID #: 368AE5333 (IA) Customer#: 5545410 Name: Osman,Jawahir Fadl Class: D ID Status: None Mohamed Address: 2530 BARTELT RD APT Audit#: 5968425 DL Status: VAL 10 Issue Date: 05/08/2012 CDL Status: None City/State: IOWA CITY, IA Expiration 12/09/2017 CDL Cert None 522462719 Date: Status: Endorsements: 3 CDL Med None Status: Mailing Address: 2530 BARTELT RD APT Restrictions: NONE Restriction None 1DDate of Birth: 12/9/1972 Supplement: Mailing City/State: IOWA CITY,IA Sex: F 522462719 History Information Convictions Citation Date Conviction Date ACD Explanation County JUR _.. 09/24/2012 09/27/2012 !N01 Fall to Yield Right of Way Johnson =IA Accidents -Accident involvement indicated does NOT mean the individual was at fault or given a citation. Accident Date Case Number 3UR _ µ 09/24/2012 '705199 _. .....____ ._.._ .._. 'i IA 12/05/2012 715386 IA Name: Osman,Jawahir Fadl Mohamed DL/ID: 368AE5333 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: -Ny-..t ....�G1 4 8/22/2013 3g ;:; t•4 rp'•••• oSvc w/ Office of Driver Services r1`\��0 `= Iowa Department of Transportation Aug. 29. 2013 9:23AM Div of Criminal Investigation No. 5543 P. 6/6 n‘01.9 IL. cv1J I .wun bl Ly olein uiiy ae IUWd oily Ivo. J/Yl 1'. 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