HomeMy WebLinkAbout14-216`IIIA
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CITY OF IOWA CITY
Authorization Number
1,q -211P
(Office Use Only)
APPLICATION FOR TAXI / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between a a.m, to 3 p.m„ Monday - Friday.)
410 East Washington Strcct
low Iowa 52240- I S� 6 Failure to complete the "required" information will result in denial of the application
91 35C 040 / 9
3- tY I,9
(3191 3Sb-5497 GAX
Firstgg
Middl Last
1. Name (REQUIRED) G( a
2. Mailing Address (REQUIRED) ��� A4014/, rt -roulA C'4L 221 SZZ G
3. Contact Information (REQUIRED) Email: F 6,21nhXV A/j,.r-'OACell Phone:
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where hen a
C5 r
6. Have you been convicted of operating a motor vehicle while under the influence of alcoholozi sin the last fare
years? rn -0 ; a
Tvpe of Offense Where y` eln
w
- ----- ------ --- to _
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense I - ere When
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8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
U. 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 aMTE 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).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
0912014
I II c rti thatI ave issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
2 b/% e� I understand that if I falsely answer any questions in this application, that this
appapp i�ay 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 215Date Z (� / `%
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
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STATE OF IOWA )
COUNTY OF JOHNSON )
bscrib,d and, sworn to before me by aV On this �`�-day of
2Vi�I62 2D1
KELLIE K.TUT(LE �t �.-f n
i' r'njM1551Dp Number 221819 /L
o cors ss; nezpires Notary Public in and for the State of Iowa
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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).
4/k(t
Sign TI' e Chief or designee I 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.
Signature of City Clerk or designee
/� �z
Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 Y" (width) and 5 Y:"
(height) and prominently displayed to all passengers.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
aerur IDRmsnDceAPPL92014anmen�ed DOC 09/2014
Sep,Iu, 2014 9:14AM Dlv of Criminal Invasfi;ation
■ . Sep. 12. 2014 9:40AMi City Clerk — Gity et lovra City
STATE OF
�
I
( I I z II: 6 IRecayd Check
to; Iowa DIVlslonoPCrlminatlnvesklgation
Support Operafiom Bureau, V' Floor
215 E. 7'h Street
12es -mohles, Iowa 50319
(515)725-6066
(5155)725-60@0 Faa
Yarn reauestina an Towa CMminal Hlatoly Record Check on:
NO., 10I PP. P. I1
DC1Acooutrt Number; 100P r F
,(ifnpplicEhk)
From; City of IOWA Cit
City Crerlc's Office
410E, Washhlt toot 5treeL~
Ioeva City, IP. 5t`2,4%
Phone; 319-356-5041 �, -.
Fax: 319-356-5497 ' ` t_
Last Name (mandato)
FSr•gE Kavte(mandal//ory)Middle
Narne (mum
mnded)
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Date of.Birtla mendarory)
Gender (mendatoPA
80cial 9CID"rity NuF(rmonlmtndjc�Female
(�On:
Without a signed waiver from thesubjtot of the request, a complete criminal his(lo
of Iowa, Chap ter 692.2• For• ayontolete criminal history record hlformation, as allow
ohtatn a waivor sl nature il•Oin the Ellb'ect of the rag nest. .
WaII.iRereage- I herebvgive pmolasion for III above mpu'ling official to conduct m Yowa criminal hlriayrccurd chedclvilh Ihe➢iVltion o(crimlgal
Invesligelion(OCt),Mty crimi�wl hfstorydala concemh;gmalhel i3rnalominedbylhe bCimey bereleeted as allo,vcd bylav,
WaiverSignatfsre:
Iowa CrxnAinal ff►stay Record Check Results �D�Iv�a�nly�
As of �/ (��'1619 / 7 a search of the provided name and date of birth zevealed;
No Iowa Cziminal History Record found with DCI
El Iowa. Cfiminal History Record attached, DCT
DCI
BPrPiven' Time-�,Ieo. 12. 0014 MOM No.
:yi,F7ER ( c Er�-� VVV'A1"JowradQ'G,gov
S'Y' r P1 R I CUSTOM �J�t[',''`_"1
TWICE, of Driver Services
F10 Boz 9204 1 Das Pi 1:A 50306-5204
Dnane_ 515-244-9124 i SGO 532 11211 Fax 515-235-1837
v, rwvt.iorradot_gov
Inquiry Date: 9/25/2014
Name: Hamad, Mogahed Mohamed
Alhassa
Address: 2654 ROBERTS RD APT 2B
City/State: IOWA CITY, IA 522462741
Mailing Adore.: 2654 ROBERTS RD APT 2B
Mailing City/State: IOWA CITY, IA 522462241
Convictions
Certified Abstract of Driving Record
DL/ID #:
241AD4645 (IA)
Customer #:
5400638
Class:
D
ID Status:
None
Audit#:
7202303
DL Status:
VAL
Issue Data:
08/02/2013
CDL Status:
None
Expiration Data:
08/02/2018
CDL Cert Status:
None
Endorsements:
3
CDL Med Status:
None
Restrictions:
NONE
Restriction
None
Date of Birth:
8/2/1980
Supplement:
Sex:
M
History Information
Citation Data - Canv:ction Date ACD Explanation County Jun
10/21/2011 X12/04/2011 � llmproper Registration ILion 'IA
]1/29/2013 .03/05/2013 592 Speed ']chosen IIA
Name: Hamad, fidgeted Mohamed Alhassa LIVID: 241AD4645
Pursuant to Iowa Code 5321.10, 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:
IOWA
D. 0. T.
Name: Hamad, vanished Mohamed Alhassa DL/ID: 241AD4645
9/25/2014
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Office of Driver Services
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Iowa Department of Transportation
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