HomeMy WebLinkAbout13-016III
CITY OF IOWA CITY
410 East Washington Street
Iowa Cit , log 40-1826 r/23
356-5040 �Z �
(319) 356-5497 FAX
1. Name
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
(Office Use Only)
2. Mailing Address �q2 C i* H Q Lo T v V a ei +V/ 1 A— r, 2 24 4
3. Telephone: Home ? 1 q- N 7 j— 6 7 t-/ o 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? Al,,
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?
Tvpe of Offense
Where
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense
Where
When
When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
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)
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)
GerWlaxiOnvEaCg
09/2012
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
7 Q At sz (r� 7 I understand that if I falsely answer any questions in this application, that this
applicaationn m>� deni d. 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_ I i a7 ! , Date T 2 C — 2� ('?
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STATE OF IOWA )
COUNTY OF JOHNSON ) p
—Sl!bscribed andL,ssworn to before me by ��wr �I �i d5 rm��mn.7 On this a� day of
� V Q1
in and
7
fk##R}*RX***#**R**Rk#4kH4f1111ff}f}RIX#**R*X**R#**R*#*Rtkf*ktHff}1fi##}1f*R*RR*X**RkR#*R*X*Rk#RkH4kkkifkk1f43ff4ffkkR#i**XX*H**kkkHfttkfkif
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).
Signatur of Police i or designee
as -l2
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.
of Ci Clerk or designee Date
Q�
Taxi cab businesses are required to provide Driver Identification cards.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
dWk&W&waegXWpmio.a 09/2012
Iowa Department of Transportation
Office of Driver Services (Toll Free) BOU-532-1121
PO Box 9284, Des Manes, IA 50019-9204 515-244-9124
140 FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
1/16/2013
DL/ID #:
379AE8597 (IA)
Customer #:
5558422
Name:
Ahmed, Emad EI Dine
Class:
D
ID Status:
None
1���R�—``
Balm
Address:
342 FINKBINE LN APT 9
Audit #:
3798718
OL Status:
VAL
Issue Date:
10/17/2009
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
06/26/2014
CDL Cert
None
522461714
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
342 FINKBINE LN APT 9
Restrictions:
NONE
Restriction
None
Date of Birth:
6/26/1974
Supplement:
Mailing City/State: IOWA CITY, IA
Sex:
M
522461714
History Information
Convictions
Citation Date Conviction Date ACD Explanation County 3UR
01/09/2011 02/09/2011 x592 .Speed 52 '.IA
Name: Ahmed, Emad EI Dine Bairm DL/ID: 379AE8597
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:
D ""••:;`% W
1/16/2013
10.
T..
D.O.T.' `
/
'••••"gy�S`'
f
Office of Driver Services
1���R�—``
Iowa Department of Transportation
Name: Ahmed, Emad EI Dine Bairm DL/ID: 379AE8597
Jan.23, 2013 4:34PM
Jan' 16. 2013 3:31PM
Div of Criminal Investigation
City Clerk - City of lotiva City
No.2674 P. 1/3
No, 3151 P. 2/2
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