HomeMy WebLinkAbout13-194 Authorization Number r 1 tA
r (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) 3S6-5040
(319) 356-5497 FAX
First Middle Last
1. Name /14/1-i c, /GI off(FLlnJr/ 461) RA-2(C�
2. Mailing Address i( 2_ (-ln«r(,Q/unit 6:1_14) f f ( IOW C/ f (/4 j S-27- c(b
3. Telephone: Home Other: 40 3 — C ?-3 -- 4?-6
4. Prior experience in transportation of passengers: lA x f 17iZ i v j i2 (L, ( U tuA C ( T'r/
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? /14
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense ` 1 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? Ni 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)
cler dtaxidrivbadg 03/2013
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
Y 4 3 A F f Vic{? . 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 ,g(To/ f3
************************************************************************************************************************************************
STATE OF IOWA )
COUNTY OF JOHNSON )
bscribed and sworn to before me by % �„s a,.-, .. \(\ o \r,. . On this 3c ' day of
v e :,k �5
,�� �_`� 713�7�
otary 'ublic in and fort'e 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).
JO"r,'ii--
Sig ture ora.'ce Chief or designee
Sig 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.
�/2 GCiLtj < - I4L1/ S � --���
Signatt�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
kf,cx,2r,balgeacp2013 doc. 03/2013
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Received Time Jun, 14. 2013 1 : 56PM No. 6204"
Iowa Department of Transportation
lir C83 Office of Driver Services (Toil Free)800-532-1121
PO Box 9204,Des Moines, IA 50306-9204 515-244-9124
IIIIIIP FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 8/30/2013 DL/ID#: 473AF1848 (IA) Customer#: 5761443
Name: Abdelrazig, Maisara Class: D ID Status: None
Address: 1102 HOLLYWOOD Audit #: 6436744 DL Status: VAL
BLVD APT 11 Issue Date: 11/01/2012 CDL Status: None
City/State: IOWA CITY, IA Expiration 11/01/2017 CDL Cert None
522407046 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 1102 HOLLYWOOD Restrictions: NONE Restriction None
BLVD APT 11 Date of Birth: 11/1/1972 Supplement:
Mailing City/State: IOWA CITY, IA Sex: M
522407046
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
03/22/2013 05/06/2013 S92 Speed WI
Name: Abdelrazig, Maisara DL/ID:473AF1848
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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E..... ®.`�I,y 8/30/2013
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Name:Abdelrazig, Maisara DL/ID: 473AF1848