HomeMy WebLinkAbout13-049Authorization Number /3— -Y 9
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APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
41 0 East Washington Street between 8 a.m. to 3 p.m., Monday — Friday.)
!12
r -CII . 9_ 5 240-1826
(319) 356-5040
(319 - 7 FAX
1. Name dI
SAilw�s� N 1 JNA �� i Last n A n`
2. Mailing Address?-? Lj �, �1 �+ � 3 o galII„1 j�
3. Telephone: Hom� _R \N IS $2 Otherk 3 )0\)
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? A/ t')
Tvpe of offense Where When
spm utir�r.���c�tindy �-/s<��
6. Have you been Gorlvicted of operating a motor vehicle while fiber t ie �f�uence of alcohol or drugs in Ae last five
years?_��
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? Al b
Type of offense Where When
8. Has your drivel's license or chauffeur's license been suspended or revoked in the last five years? I1L'
Tvoe 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)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVIE
You must apply for an individual Department of Criminal Investigation Report (form available upon request) The re-
port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli-
cation.
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
derkP.&,d badg 09/2012
I here�iy er�Ity that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
0 y = H� X12 1i . 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 S�G A_A� Date_
+#+aa+++a++++++++++++++++++++++++++++++++++a++aa+aa+++aaa++a*+++++++++++++++++a+++++++++++**#+++++++++*++*++++++++++++++++++++++++++++++++++++++
STATE OF IOWA )
COUNTY OF JOHNSON )
p scribed and swornitabefore me by Saw so_x) o r -y 6 (— . On this S� day of
, - 77f &6
7F WE K. TUTLE
"
Notary Public in and for the 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).
Signature of �pIloe 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.
k-%"iLtl
Signature of City Clerk or designee
Taxi cab businesses are required to provide Driver Identification cards.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
Date
ded "dnvbadgeapp2010.d 09/2012
Iowa Department of Transportation
Office of Driver Services (roll Free) 800332-1121
PO Box 9204, Des Moines, IA 503D&9204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
2/28/2013
DL/ID #:
059AA0923 (IA)
Customer #:
1559313
Name:
Omar, Sawsan Khalil
Class:
D
ID Status:
None
Address:
2240 9TH ST
Audit #:
5483219
DL Status:
VAL
06/23/2012
07/11/2012
Issue Date:
09/01/2011
CDL Status:
None
City/State:
CORALVILLE, IA
Expiration
01/01/2016
CDL Cert
None
522411567
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
2240 9TH ST
Restrictions:
NONE
Restriction
None
Date of Birth:
1/1/1972
Supplement:
Mailing City/State:
CORALVILLE, IA
Sex:
F
522411567
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
County
3UR
06/24/2008
,07/15/2008 1
592
Speed
X52
IA
11/12/2011
12/12/2011
#M14
-Fall to Obey Trafflc,Sign/Signal_
'52
IA
06/23/2012
07/11/2012
S92
Speed
52
IA
Name: Omar, Sawsan Khalil DL/ID: 059AA0923
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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2/28/2013
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Office of Driver Services88PR
Iowa Department of Transportation
Name: Omar, Sawsan Khalil DL/ID: 059AA0923
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Div of Criminal Investigation
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Received Time3Feb.22.-2013-11:31AWf—No.4220