HomeMy WebLinkAbout13-159 tAuthorization Number /3 J/�67
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 52240-18p,,
."1.51.1-3-5675-0.40i1_51—k- `J
(3I-9j356-5497 TAX
First Middle, L st
1. Name m'T e. /��b 14 i 2Q�1 `L2, 1jI
2. Mailing Address 2/ r-a R4011,51r 2-1) i <</2 G11- i 1 iri
3. Telephone: Home 73/q 1/(76, 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? /t/c2
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
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7. Have you been convicted of any traffic offenses in the last five years? /v
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? 4/d
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)
71/(,
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)
clerkftaxidrivbadg 03/2013
(� A S 70/ 3
I hereby certify that 1 haye issued to me by the Iowa Department of Transportation a valid Chauffeur's license number •
c> ,r9.Qre- t a .7-- f/A/1 /6") 1 3 . 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 7/2 ?/./3
7/37'75
STATE OF IOWA )
COUNTY OF JOHNSON ) 66-4/W/e—
lSubscribed and sworn toefore me by 12n/2 — i / r011=27Y1-erl. On this •-&—/) day of
KELLIE K.TUTTLE I C G 6
o i 'r Commission Number 221819 Notary Public in and for the State of Iowa
nriroC
•
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).
ignature of Police 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.
<' l -{n yt/ • / / >/ /
Signa•ure of City Cle or designe 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
clerkttaxidrivbadgeapp2010.doc 03/2013
x::.1. 25. 2013 11 :42AM Div of Criminal Investigation No. 1316 P. 3/3
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Iowa Department of Transportation
w Office of Driver services (Toll Free)900-532-1121
Il 5030
PO Box 9204,Des Moines:IA 50308-9204 515-247-9124
NoloFAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 7/18/2013 DL/ID#: 684AJ7013 (IA) Customer#: 6082673
Name: Mohamed,Gamerelanbia Class: C ID Status: None
Ismail
Address: 2608 BARTELT RD APT 2D Audit#: 6847013 DL Status: VAL
Issue Date: 04/09/2013 CDL Status: None
City/State: IOWA CITY, IA 522462730 Expiration Date: 01/01/2018 CDL Cert Status: None
Endorsements: NONE CDL Med Status: None
Mailing Address: 2608 BARTELT RD APT 2D Restrictions: NONE Restriction None
Date of Birth: 1/1/1957 Supplement:
Mailing City/State: IOWA CITY,IA 522462730 Sex: M
History Information
CLEAR DRIVING RECORD
Name: Mohamed, Gamerelanbia Ismail DL/ID: 684AJ7013
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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ebt Iowa Department of Transportation
Name: Mohamed, Gamerelanbla Ismail DL/ID: 684AJ7013