HomeMy WebLinkAbout15-0346-3
Authorization Number /
r g (Office Use Only)
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APPLICATION FOR TAXI / MOTORIZED PEDICAB VEHICLE DRIVER
CITY OF IOWA CITY (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday.)
410 East Washington Street
Iowa City. Iowa 52240-1326 EfNiar fe i�lp&t '` w"..Y((d..enial of@.`1&C.aa�...w........_......._
(319) 3S6-SO40
(319) 356.5497 FAX
First MiddleLast
1. Name (REQUIRED) l V\n }{,(
Zee -
2. Mailing Address (REQUIRED) Vl""ktT ee-+Sp- PL- i 10 ok G'1k-q LA <�2-1"A6
3. Contact Information (REQUIRED) Email:
4. Prior experience in transportation of passengers:
0 - (v- Cell Phone
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? %U 0
Type of offense
Where
um
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?'D
Where
7, Have you been convicted of any traffic offenses in the last five years?
.- V
F"e 4
S 17'L
8. Has yA driver':
Bog -of offense
P
license or chauffeurs license been suspended or revoked in the last five
Where
When
rl P"1TT'i1
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
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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 (forint available upon request).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
0912014
I hereby car6fy that II have issued to me by the lovtra Depariment of Transportation a valid Chauffeurs license number
I understand that if i falsely answer any questions in this application, that this
application may be denied. I derstand that if I falsely answer any of the questions in this application, that this application vvill
be denied. I agree that in m ing this application, I consent to allow agents or employees of the City of Iowa City, Iowa, in
their discretion, to examine anand all records and documents relating to this application, and I further agree that, if a license
is granted, to comply at all time with all of the provisions of Title 5. Chapter 2, of the City Code. (Needs to be signed in front
of a Notary Public) c�
Signature of Applicant ` (o�3 date c A S
-, u
YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY
CLERICS OFFICE. Authorized taxi driver names are placed on the city website at lcgov.org.
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me byr�y;va5 n,.t'tt_ On this __,_,_ day of
in and for the State of Iowa
#d*%%*d***9d*rt*3***di******is*dkfrt*#y,*idled#*#%*fise**irt******k#k*d**#*k*led*dki**ilei#3*},**3****3*k*.k**3%*k*d*#krt%kdfi%dddtki(t.^.3:}dit.'s::rtdiiisik*di*3
I have reviewed this application, DCI report, and the State certified drying record of tMs appiicanr and have deter-
mined that there Is no information which would indicate that the issuance would be datelmantal to the safety, health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
Signature of Poly hfef or designee
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.
Sign ure of City Clerk or designee
:6: ---
/Dale
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/Y" (width) and 5'/z"
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
ClerkTAXIDRNBADGEAPPL92014amended.DOC 09/2014
�sP
2/19/2015
GT
570AG6289(IA)
•"F.«w.,.ti-eixwww'
Mohamed, Hatim
Class:
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Restriction
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Addlrasm
24:1.7 PETSEL IPI.. UNIT 1 Audit g;
8436708
Wliwmwow uw rrvrrr ,r ` I ln
0"1A'fN's of pbi➢y(7p'.sepvl'.tia a^
Johnson _,
Issue Data
09/1.:1/20:1.4
p1I EkbktZ204 i Ol^.aA 11469111na IIA. `W1.%irolr-WAX
IOWA CITY, IA
Expiration
flhtir9t 5152.4+4 912.4 C 89(%812-1 121 1 Fax: 5i!r-23*f_ an
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522463609
Date:
'mm hoax adaF rpm
Celrtiii'iand Abstract of IDrIlviing Ilia: Dlyd
Inquiry Date;
2/19/2015
DL/ID #;
570AG6289(IA)
Named
Mohamed, Hatim
Class:
A
Restriction
Ahmed Husseen
. ¢'..7s.
Addlrasm
24:1.7 PETSEL IPI.. UNIT 1 Audit g;
8436708
:Seat ll:Sellt VW atuoutl
Johnson _,
Issue Data
09/1.:1/20:1.4
City/State°
IOWA CITY, IA
Expiration
01/01/2016
7fA
522463609
Date:
;592
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:Ho llr+aoVY
Endorsements® NONE
Mailing Address; 2417 PETSEL PL UNIT I Restrictions; NONE
Date of Bertha 1/1/1973
Mailing City/Stater IOWA CITY, IA Sem M
522463609
DL Stables: VAL
CDL Status; VAL
CDL Cart
CGIW u Cflown Dante
Status:�Intrastate
Explanation
CUL Mad
None
statuw
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Restriction
None
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tatatlon Valeo
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ACD
Explanation
Cor.amity
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. ¢'..7s.
Ela/.i IIG/2011.2
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Johnson _,
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111/29/X014
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Accidents •- Accident invoivelmetnt ilndlleated does NOT mean the lundivlldauai was at fault air given a citation.
-4'aePp,Bn'lt Date
13�2/19�+8,/2dY1�1
Cis°, Hu wber
Name; Mohamed, Hatim Ahmed Hussesn.DL/ID; 570AGG289
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.
o 4
Jan.14. 2015. 10:51AM Div of Criminal Investigation No.7964 P. 9/9
dan. IL. iu1D d.4orM c,iy clerk - crty ar Iowa city No. 5536 Y. Z
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215 1g.,71h street
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Phone: H9-3664041.
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o Iowa Criminal ffistDry Record% with DCI
lomr ft Crvlwnal, Histoxy Record maolr.eA .M.1 # .....................................
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Received Time Jan. 12.:2015 1:44? Mo.'7ii1
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