HomeMy WebLinkAbout13-193 • Authorization Number 113 - / 93
� - 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 _, 2240:1826
4319) 3 - 1-11-) BJZ2,
(319) 356-5497 FAX
First , Middle Last
1. Name Yti� 1 'v F�z\.`� ; 5�,��
2. Mailing Address 3 6 A ; ) 4 , 5 \ Win"-` c; -1 Y 1 Ia l; 2_7- a
3. Telephone: Home 319 4-7( /7?z i 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? N".CD
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? v-\c>
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? .;"(2 >
Type of offense Where When
n/ o-(1 / v-c -,9 ' S
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? A c,
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)
o
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)
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
(t-tk A C 2 \ 6 . 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 ( > , s
STATE OF IOWA
COUNTY OF JOHNSON )
Supscribed and sworn to before me by r< 1q-i. ) Sc�€ . On this 3 67 day of
w.�. --ZO!3
1*1
SONDRAE FORT ��'��J�`'`Commission Number 159791 Notary Public in an for the State of Iowa
My Ct i balun G,Nlres
;7di0/5"
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).
/ Q -?�`l�
Sign re of P', e Chief 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.
e - 5'- -
Signabre 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
clercitaxidrivbadgeapp2010.doc - 03/2013
Rug. 21. 2013 3: 54PM Div of Criminal Investigation No. 3388 P. 2
. Aug. lo. Lull 4:4)rm lily LIerK — Wry oT Iowa Lily No, i//4 P.
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rt rem aunina1XligovRecord attached,)5aft .
Received Time Aug, 16. 2013 4:43?M,No., 28820 n
Iowa Department of Transportation
..`• Office of Driver Services (Toll Free)800-532-1121
PO Box 9204,Des Moines, IA 50306-9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 8/16/2013 DL/ID #: 144AC2108 (IA) Customer#: 5262644
Name: Saeed, Khalid Azharl Class: D ID Status: None
Mohamed
Address: 36 ANISTON ST Audit#: 6182099 DL Status: VAL
Issue Date: 08/03/2012 CDL Status: None
City/State: IOWA CITY, IA 522402216 Expiration 08/17/2017 CDL Cert Status: None
Date:
Endorsements: 3 CDL Med Status: None
Mailing Address: 36 ANISTON ST Restrictions: NONE Restriction None
Date of Birth: 8/17/1983 Supplement:
Mailing City/State: IOWA CITY, IA 522402216 Sex: M
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
10/03/2008 12/09/2008 592 Speed Johnson IA
10/01/2010 10/25/2010 592 Speed Lee IA
08/26/2011 09/19/2011 593 Speed Johnson IA
02/09/2012 08/10/2012 F02 No Child Restraint Johnson IA
02/09/2012 08/10/2012 E50 Defective Equipment Johnson IA
Name: Saeed, Khalid Azhari Mohamed DL/ID: 144AC2108
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:
r.1174)114
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ger: :tig a eiefoo4
yr3lot,tad- IowaDepartment of Tranof Driver sportation
Name: Saeed, Khalid Azhari Mohamed DL/ID: 144AC2108