HomeMy WebLinkAbout15-086CITY OF IOWA CITY
410 East Washington Street
Iowa City, low, S2240-1826
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. I( C2
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday – Friday)
1. Name (REQUIRED) L First
2. Address (REQUIRED) IeA6
3. Contact Information (REQUIRED)
Middle
l f t- Last
T y .-�-.4 . S'-2
Email: t TflE�04 A7 /f. oa.n X70
(All written communication sent v a email) well Phone:
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED)
5. Prior experience in transportation of passengers:
w >k t 17
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? /0G'
Type of offense
_ W
here
What happened to the charge? (Circle one)
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested/ charged with any traffic offenses in the last five years? J'4 - J
Type of offense
Where
When
V
What happened to the charge? (Circle one) J—
CC00VI Dismissed Deferred suspended Plead Guilty
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five ears
Other —
pe of offense years?
Where
otJ G :J%'o F 4-1N Where
`o wrt , I rf /A
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 STATEC
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE C IF
You must apply for an individual Department of Criminal Investigation Report (form avail Wry(
upfeq r _
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTA RIj
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby cerci�L,th I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
336 /i, i�03 issued one*le-/l expiring on oS-/o- Zo/f' I understand that if I
falsely answer any questions in this application, that this application may 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 authorization to be a taxicab driver 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 r ✓7 o L. ✓ �(�,,, y -7
Ll -) y -/ s-
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STATE OF IOWA }
COUNTY OF JOHNSON )
and sworrrto before me by Mc n .d�ecQ i�. i "nSS.11
w on this ( 4-tti, day of
in arM for the State
have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that
there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi-
dents of the City of Iowa City (Title 5, Chapter 2, City Code).
Expiration date of Chauffeur's license /-A/1 - Ao
Sig7fureo7oyce hfefordesignee
/-/-/Z/-' /51--,
Date
AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO
MORE THAN ONE YEAR FROM THE DATE LISTED BELOW.
S�'ignajju��re of City Clerk or design
Approved application
DCI report
State certified driving record
Website update
t �-Z/e/�-
Date
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Office Use Only
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SMARTER I SIMPLER I CUSTO E49 DRIVEN WbVwOVVadOt.C�OV
Office of driver Services
PO Box 9204 Des Moines, kA 50306-9204
Phone: 515-244-9124 ( 800-532-1121 I Fac 515-239-1837
wwwJowsdoLgov
Certified Abstract of Driving Record
Inquiry Date:
4/14/2015
DL/ID #:
336AE9503 (IA)
Customer #:
5485805
Name:
EI Hassan, Mohamed
Class:
D
ID Status:
EXP
01/02/2015
Medani
B51
No Driver's License
Oohnson
'IA
Address:
1076 CHAMBERLAIN DR
Audit #:
8997945
DL Status:
VAL
Issue Date:
04/10/2015
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
01/16/2016
CDL Cert
None
522402952
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address;
1076 CHAMBERLAIN DR
Restrictions:
Corrective Lenses
Restriction
None
Date of Birth:
12/27/1982
Supplement:
Mailing City/State: IOWA CITY, IA
Sex:
M
522402952
History Information
Convictions
Citation Date
Conviction Date
ACD
Explanation
_ County
IUR
03/29/2014
'05/07/2014
1592
Speed (10 mph & under in 35-55 mph zone)
',3ohnson
-IA
01/02/2015
'02/19/2015
B51
No Driver's License
Oohnson
'IA
Sanctions
Type Effective End ACD Explanation Occurrence IUR IUR
Suspended 108/11/2014 10/06/2014 jD53 ,Non -Payment of Iowa Fine !IA IA
Name: EI Hassan, Mohamed Medani DL/ID: 336AE9503
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:
o~o&v�IClf q���'O�
IOWA '-wl
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1�4,�=.r'•.. : i�rf 4/14/2015
State of Iowa
Division of Criminal Investigation
215 E. 7" Street
Des Moines, Iowa 50319
Phone: 515/725-6066 Fax: 515/725-6080
Iowa Criminal History Record Check
Walk -In Request
Your name:t-o - N .SSA (%
Address: /cE c R M tat P�- t.;� w V
City/State/Zip: e ( rr s .�, 5-22 c/:55
Phone #:KEe7s-7y
Requesting an Iowa criminal history record check on:
Fill in all shaded areas.
Last Name 4pethdo(mandatory)
First Name Primer Nombre(mandntory)
Middle blame S'eg,redo Nowbre('recommended)
,rL 11,4fS/p,
r--I,'HA1-7fD
,ter ,� l
Date of Birth Fecha Naclmlento (mandatory)
Gender Genero (mandatory)
Social Security (recommended)
12 2 _�y Z
® Male El
L Z �-
�Number
6-! z
Waiver Signature Ftrma ('If the request is on yourself, please sign. If the request is on someone else, write N/A)
nXt test 1,NI v
Results
As of 1 1 (S , a name and
date of birth check revealed:
o
No record found
_
❑ Record attached DO #[
:P
M
s n
DCI initials
r
�
Receipt
Number of requests x $15.00
per last name = Total amount $ 1
5. 00
Method of payment: cash
money order check #
MasterCard or Visa
(East 4 digits)
Cardholder's name
DCI initials
--------------------------------------------------------------------------------------------------------------------------------------------
Credit Card #
Exp. Date
DCI -83 (09/09/ 10; Revised 10/ 1/10; form reviewed 08/ 11/14)