HomeMy WebLinkAbout13-155 Authorization Number 15 - / 5c)
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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) 356-5040
(319) 356-5497 FAX
First Middle Layt
1. Name (‘ 'YA_Ot /� emote\r� -V1Q,\
2. Mailing Address 15-4.Z v/�l��vz cx t /dZ&J C i y - l 4 ` 2:4-0
3. Telephone: Home ,--7) I — 3 "-g62-,@ Other:
4. Prior experience in transportation of passengers:
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5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /110
Type of offense Where When
6. Have you be n convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? /\) 0
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? y.P S
Type of offense 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? N 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)
AJO
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)
clerkitaxidrivbadg 03/2013
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license num l eer
53A`� .1 5 12 I . I understand that if I falsely answer any questions in this application, that th s
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 D7/2-6 I Z6/3
STATE OF IOWA
COUNTY OF JOHNSON )
Subscribed and sworn to before me by �S Q K��- `a" 21�7�1
. On this day of
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awt
KELLIE K.TUTTLE /` -e c ( � e /„ --717/(e_
commissi``oon"'Cumber 22.1819 Notary Public in and for the State of Iowa
!OW /5�1
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).
•
ignatur 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.
t�
Signa 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
clerkttaxidrivbadgeapp2010.doc 03/2013
,Jul. 24. 2013 1 :46PN1 Div of Criminal Investigation . . . �No. 1181 PP. 4' •
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Received Time Jul. 19, 2013 2: 20PMiit,o. 0775 .
filllIowa Department of Transportation
) Office of Driver Services (Toll Free)800-532-1121
PO Box 9204,Des Manes,IA 50306-9204 515-244-9124
IIIIIP FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 7/18/2013 DL/ID#: 553AG3581 (IA) Customer#: 5882445
Name: Khalid, Osama Saeid Class: D ID Status: None
Address: 1542 DICKENSON LN Audit#: 6123240 DL Status: VAL
Issue Date: 07/13/2012 CDL Status: None
City/State: IOWA CITY, IA 522409111 Expiration Date: 01/31/2016 CDL Cert Status: None
Endorsements: 2 CDL Med Status: None
Mailing Address: 1542 DICKENSON LN Restrictions: NONE Restriction None
Date of Birth: 1/31/1966 Supplement:
Mailing City/State: IOWA CITY, IA 522409111 Sex: M
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
09/29/201211O/02/2012 1S92 -p _
,Speed Johnson IA
12/02/2012 .12/13/2012 ,N01 !Fail to Yield Right of Way Johnson IA
Name: Khalid, Osama Saeld DL/ID: 553AG3581
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:
ptjCIf"'a
%o,. /.�,��.,40 7/18/2013
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�' �f3YtNs Office of Driver Services
1owaDepartmetofTansportation
Name: Khalid, Osama Saeid DL/ID: 553AG3581