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Home My WebLink About14-133Authorization Number 1q—L43) t t t^ r Office Use Only) ! I "°Ill WAS w` r1 CIN OF IOWA CIN APPLICATION FORT t/MOTORITED PEDICA VEHICLE DRIVER (Police Department review must be made 410 East Washington Street between 8 a.m. to 3 p.., Monday—Friday.) Iowa City, Iowa 52240-1826 (319) 356-5040 (319) 356-5497 FAX Furst R Middle ILast {� 1. Name .._._.------- ---------------------------- ..._.__._____ --- .--------- ________ -------------- --------------- 2. ----- --- - 2. Mallin ddress, !/ �cd °t" '*P �°atro�a v �iaw. � � ad arc.---- __ --------------------- 9 _._ ._._._._.__�____ _ _____ 3. Telephone: Home __-_r 1_ _ �. ._ .� __ 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? +- « I 6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five years? n o jape of Offense 7. Have you been convicted of any traffic offenses in the last five years? it 0 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? NO a W I 9. Have you ever applied to be an Iowa City tax! driver using a different name? If yes, please provide the name(s) 6 r> ,, • • . 0- , • r R11;4* •••, ,-- • :•..• You must apply for an individual Department of Criminal Investigation Report (form available upon request). (OVER FOR REQUIRED SIGNATURE AND NOTARY) dniJtmdddvbadg 03/2014 I hereby certii that I have issued to me by the lova Department of Transportation a valid Chauffeur's license number �6 a4a 2 7 . 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 appication, 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 he sigrsed in front of a Notary Public) Signature of Applicant G . Bate > G y 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. STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by `btc e`r� ! �_ a. On this _._._gym -t day of r-9iXa""i"— cmmv..9.nnnvER Notary Public c in "id for ththe State Su.e offQ) ra wa 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 q ........... Chief or designee � L:�ate 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. ax -e« �"ld',� Signa7 C ~tu of City Clerk or designee Date Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 %1' (width) and 5 %11 (height) and prominently displayed to all passengers. Office Use Only Approved application DCI report State certified driving record Website update deAJtadd&badgeapp2014.dw 03/2014 Name: AI -Hassan, Julia Medan! DL/ID: 463AF2497 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 whelr:of, .f. have caused my w9riaturr surd the seal of the Department to be set upon this document, at Ankeny„ Iowa this date:: ° rV;jf aif 6/20/2014 IOWN, Office of Driver Services Iowa Department of Transporatlon Name: Al Hassan, Julia Medanl DL/:II'11 : 463Ai 2497 Department Ii �a o ' !d I spcm die aVI VI 04fice Li( DMa '""ri"i"»"&N iia ("rd 11110110) Pi)('rv:u 112 11(I/ 1 psi 11810K "Y°NK, IITaI*« plf'NnI , lA 15006 "125.1 11151 W "01-9124 RAX: 111:tl° KIM" C41t'tMed A.l%ANtt"rr"Ict of Dirivinig IRecard Inquiry Datea 6/20/2014 DL/ID #; 463AF2497(IA) Customer #: 5402245 Name: Al -Hassan, Julia Class: D ID Status: None Medan! Address: 2401 HIGHWAY 6 E Audit #: 4632497 OL Status: VAL LOT 3801 Issue Date: 08/27/2010 CDL Status. None Ciity/,Stator IOWA CITY, IA Expiration Date. 10/06/2015 CDL Cert Status: None 52240682.3 Endorsements: 3 CDL Med Status: None Nulling Address: 2401 HIGHWAY 6 E Restrictions. Corrective Lenses Restriction None LOT 3801 Supplement: Date of Birth, 10/6/1975 Mailing IOWA CITY, IA Sem F City/State: 522406823 H IIstolry linfD111r1a'tIloin Name: AI -Hassan, Julia Medan! DL/ID: 463AF2497 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 whelr:of, .f. have caused my w9riaturr surd the seal of the Department to be set upon this document, at Ankeny„ Iowa this date:: ° rV;jf aif 6/20/2014 IOWN, Office of Driver Services Iowa Department of Transporatlon Name: Al Hassan, Julia Medanl DL/:II'11 : 463Ai 2497 0s®Jon�25. 2O14Q, 2 ..... Cab Div of Criminal Invest,gation (FAX'3103302allo.3499 P•„102®002 Too Iowa IIDWSIoa a¢'CrpuanVmap IIaavesa gagapn SUIPPOr¢ Opgeira¢pmr Burea%, :K” Floor 316 X. 7°a 8¢tros¢ Dos Mcilsaays down 5031.9 (510)725-6066 (3d6) 7254060 fax TDOd Aeaauaa¢ Number 99674� $pr V@sabP.e) Fromaa Yellow Cads of Iowa City rA Bo 4420 era &¢y'8 03344 'roMIP.CIVU� /7 mmane. 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