HomeMy WebLinkAbout13-025- r
CITY OF IOWA CITY
410 East Washington Street
Iowa Cil 40-IS2¢_,/.
(3-t'�Il 356-5040
(319) 356-5497 FAX
1. Name
2. Mailing
3. Telephi
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
i -2"D
(Office Use Only)
4. Prior experience in transportation of passengers: Adt'dy Th4A
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?
Type of Offense
Where
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense Where
8. Has your drivers license or chauffeur's license been suspended
Type of offense
Where
When
revoked in the last five years?
When
CG
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)
6e dr,m dg 09/2012
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
lg0 Z-/ 3Z � . 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 a I �� �� 3
STATE OF IOWA )
COUNTY OF JOHNSON )
and sworn to before me by
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On this /cam day of
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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).
Sig lure of li a Chi t 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.
Signal f 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
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State of Iowa
Division of Criminal Investigation
215E7`hSt
Des Moines IA 50319
Ph. 515-725-6066 Fax 515-725-6080
Iowa Criminal History Record Check
Walk -In Request
Your name s
Address 0 WA
City/State/Zip I oWa e I-r�
Phone# 71
Reauesting an Towa criminal history record check on:
Fill in all shaded areas.
Last Name Apellido (mandatory)
First Name Primer Nombre (mandatory)
Middle Name Segundo Nombre (recommended)
AhM4
Atir
om{P/-
Date of Birth Fechha�N/acimienro (mandatory)
Gender Cenero (mandatory)
Social Security Number (recommended)
Oql q�a--1
43Tale ❑Female
671 — 35_ o 15 I
Waiver Signature Firma (If the request is on yourself, please sign. If the request is on someone else, write N/A.)
Results
As�No
of 0" I - I a name and date of birth check revealed:
record found
❑Record a ched, DCI #
DCI initials
Receipt
Number of requests �_ x $15.00 per last name = Total amount $
Method of payment: Ocash. ❑money order
Cardholder's name
DCI initials
DCI USE ONLY
' 4
L.
W
❑check # El MasterCard or Visa
Last 4 digits of MC or Visa
Credit Card Number # Exp. Date
Iowa Department of Transportation
Office of Driver Services (Toil Free) ON -532-1121
PO Bot 9204, Des Moines, !A 503DO-9204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
2/1/2013
DL/ID #:
248AD4337(IA)
Customer #:
5409160
Name:
Ahmed, All Omer Ali
Class:
D
ID Status:
None
Address:
2401 BARTELT RD APT
Audit #:
6574268
DL Status:
VAL
IA
Issue Date:
12/28/2012
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
09/22/2013
CDL Cert
None
522462701
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
PO BOX 2532
Restrictions:
NONE
Restriction
None
Date of Birth:
9/22/1968
Supplement:
Mailing City/State: IOWA CITY, IA
Sex:
M
522442532
History Information
Convictions
Citation Date Conviction Date ACD Explanation County IUR
10/22/2009 .,,. .,,., 12/15/2009:S92 iSpeed,._ ._._ ., 152 IA
_ _. ,
09/01/2012 11/08/2012 ,M14 ;Fail to Obey Traffic Sign/Signal 52 IA
Name: Ahmed, All Omer Ali DL/ID: 248AD4337
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:
•--•:�T/p�t,
2/1/2013
IOWA ?'
D.O.T.=�4
Jar
.......... S�=
Office of Driver Services
Iowa Department of Transportation
Name: Ahmed, All Omer All DL/ID: 248AD4337