HomeMy WebLinkAbout13-179 Authorization Number I J Cl
r 1 (Office Use Only)
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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
(319) 356-5040
(319) 356-5497 FAX
First Mi Middle Last
1. Name f Lo k 1� m / /(1 S2 )1,11 ', ryv4yj
2. Mailing Address V) / �?a) ) YV/i G )t Y T/ "5,21 U
3. Telephone: Home-3n 33 ? J 2) Other: -7 J G'6 47i
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? /V 0
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? fV)
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)
l��V!
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)
clerkltaxidrivbadg 03/2013
I IJereby certify that Ive issued to me by the Iowa Department of Transportation a valid Chauffeur's license numbe
(a� )� T, 1--,-,3‘-b r
. 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) I
Signature of Applicant �— Date J7S/ / 0 e L
STATE OF IOWA )
COUNTY OF JOHNSON )
'scribed and sworn to before me by 1 r ,0 Q�'YI�c'( Si i e nACt-b'..- . On this ��( day of
_ut_ �-U) >_ I
K c ( r-e )� t 1 t Q
u. �(s KELLIE K.TUTTLE Notary Public in and for the State of Iowa
4q urnmission Number 22181
My on,missi
n E pires
.**.**........**.*.**.*..*.**** *.**.**. *. . .* ******* *.*.************.**************************************************************
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).
A,r
tI ..fa .?-a —U
Signatur- of 'olice ' h v-f or sesignee 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.
.
c:':,,_ -.Z-V
Si re of Ci Clerk or designee Date
Taxi cab businesse re required to provide Driver Identification cards. Cards must be 81/2" (width)and 5 '/z"
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
derk/taxidrivbadgeapp2010.doc 03/2013
. , ;Aug. 6. 2013 . 4:38PMi, i ,GDiv of Criminal rInvestigation - ' rNo.�1754 P. 2/5 '-
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Received Time Aug. 1. 2013, 12:25P.Wp.. 2251 - '
ARTS Page 1 of 1
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� Iowa Department of Transportation
, Office of Driver Services (Toil Free)800 32-1121
PO Box 9204,Des Moines,IA 50306-9204 515-244-9124
1411. FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 8/3/2013 DL/ID #: 651AH5368 (IA) Customer#: 6042906
Name: Sulleman, Mohamed Class: D ID Status: None
Muslim
Address: 2401 HIGHWAY 6 E APT Audit#: 6868071 DL Status: VAL
3802 Issue Date: 04/16/2013 CDL Status: None
City/State: IOWA CITY, IA Expiration 07/23/2018 CDL Cert None
522406720 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 2401 HIGHWAY 6 E APT Restrictions: Corrective Lenses Restriction None
3802 Date of Birth: 7/23/1977 Supplement:
Mailing City/State: IOWA CITY, IA Sex: M
522406720
History Information
CLEAR DRIVING RECORD
Name: Sulleman, Mohamed Muslim DL/ID: 651AH5368
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:
ot.... CIf.(j, ,, 8/3/2013
*i IOWA Sr a ee40,1„4
oat.D. O. Uzi
EcFof . fc Office
of Driver Services
. Iowa DepartmrSrvTransportation
Name: Sulleman, Mohamed Muslim DL/ID: 651AH5368
http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 8/3/2013