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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319 356-5040 QAL� Feb d$
(319) 356-5497 FAX
First
1. Name Cctm'Y
Authorization Number / 3 — 43
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
2. Mailing Address L') -] JJ a e 1-F lkz'dl 74
3. Telephone: Home ':Z!
4. Prior experience in transportation of passengers:
11 M
Other:
Last
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
Where
When
N/P
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
7. Have you been convicted of any traffic offenses in the last five years?
When
TVpe of offense Where When
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8. as your drivers!/ licensese ar chauffeur's license been
.Type of offense Where
IV
ma•„
or revoked in the last five yeaea �s'�
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 REVIEW
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)
GeM1Aaxmriwatlg 09/2012
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
2 bb (� n 'amt mY, I understand that if I falsely answer any questions in this application, that this
denied.
�'
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
STATE OF IOWA )
COUNTY OF JOHNSON )
Subspribed and sworn to before me by 5 ; r On this r)s� day of
0.V. —�
r �,� �`��1 ��
Nota is in and for th6 State oft6wa
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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).
Signa ure of P lice Cifief o 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.
Signatbre 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
a-ag- /--�
Date
GetkAuidnvbadgeapp2010 d 0912012
Page 1 of 2
Iowa Department of Transportation
Office of Driver Services (Toll Free) WO -532-1121
PO Box 9204, Des Manes, IA 503D6-9204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 2/22/2013
Name: All, Samir Isameldeln
Address: 2427 BARTELT RD APT
2B
City/State: IOWA CITY, IA
522462710
DL/ID #: 266AD7808 (IA)
Class: D
Audit #: 4018270
Issue Date: 01/14/2010
Expiration 11/03/2013
Date:
Endorsements: 3
Mailing Address: 2427 BARTELT RD APT Restrictions: NONE
2B Date of Birth: 11/3/1985
Mailing City/State: IOWA CITY, IA Sex: M
522462710
History Information
Convictions
Customer #: 5429309
ID Status: None
DL Status: VAL
CDL Status: None
CDL Cert None
Status:
CDL Med None
Status:
Restriction None
Supplement:
Citation Date
Conviction Date
ACD Explanation
County
JUR
01/09/2009
X02/06/2009
592 Speed
•S92
52
IA
08/28/2009
.10/16/2009
,Speed
52
IA
09/09/2009
11/25/2009
592 Speed
52
IA
01/28/2012
04/04/2012
'Improper Parking on Highway
52
IA
Accidents - Accident involvement indicated
does NOT mean the individual was
at fault or given a
citation.
Accident Date
Case Number
JUR
07/27/2012
696745
IA
Name: All, Samir Isameldeln DL/ID: 266AD7808
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:
........f" 4
D
2/22/2013
IOWA
D. O.
7f •••••"g
11tO,,=
Office of Driver Services
"N
Iowa Department of Transportation
2/22/2013
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