HomeMy WebLinkAbout15-117� Ill i
AN CITY OF IOWA CITY
410 East 1V25hinglon Strcct
low Iowa 52240 -IS 6
—(#tilt 356-5040 / 9�p
(7191 356-5497 FAX I
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Authorization Number 15— h
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APPLICATION FOR TAXI 1 MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be mad« =. =wgon a a.m. to 3 p.m„ Monday — Friday.)
Failure to Complete the "required" information will result ,n venial of the application
Name (REQUIRED)
Mating Address (REQUIRED)
Contact Information (REQUIRED)
Email. ! �AZ�� 00 CfQ4 Cell Phone V
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
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol
yearsv--No
Tvoe of Offense Where
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense
DC7
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When
8. Has your driver's license or chauffeurs license been suspended or revoked in the last five years?
Type of offense Where
6. 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�TATE ERTI
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)
I hherreb c it that lave issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
�Nl_ k, � 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 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 ofApplicant „1(_ �� Date D I
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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 il On this 2 -(P4 -A --day of
ertao� ,/
sr�+� KELLlEK.TUTrrE L.Lr K �7y�
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rcmmisson ,lum4er 22.18
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 dell
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).
Sig 616 Chief or designee -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.
: ',� . -A�MAJ
Signature of City Clerk or designee
// �z
Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8'/z" (width) and 5
(height) and prominently displayed to all passengers.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
aerirranRrvanocenrPrs2maa�ienxaoac 0912014
x 5:p, 16, 2014 9'144 Dlv of urin nal Invsstiaation
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SEP. 0• 2014 94DAr COY Clerk — Gity at Iowa Gi[Y
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S`10EM OF 1.0T11A
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to; IowaDfylstonofUrninalThvesfigatioa
5uppost Oparatinhs Bureau, e' Fioor
215 E. I" Street
Ties Moines, Iowa 50319
(3151)985-6066
(515)725-6090 Fax
I am i-eauestin¢an Iowa Qimfi al HiatorvRecord Check on:
Neo.,iuO of PP. 1]
DCI AccountZfulnber; 100P -p
-- (itopplicshlo) — -
From; City of Iowa Cl
City Clerk's Office
FSree Name men6aO
410L. W9shfn ton Street
Iowa City, U Mg4p:
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Phonei 319-356-6041
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Fax: 319-366.5497
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Date of Birth (mondaiery)
Gender (/,endetoro
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WaiverAlfopwat(Oh. Without a signed waiver fl'Om 1heshbjectof the request, a colnptnte criminal history record may hot
be releasable, per Code of Iowa) Chapter 692.2, Fol, goto pieie criminal history mord flltormation, as allowed by law, ofWays
obtainawaiverei nafw'etYomthesub'eeforfhere pest..
Waiver Release-thuebvgivepcmis,ionforrheebove'. uUUVngONO re conductmIowacrimhralhkimyrecoracheckWill) theDivisionpfcriml;lar
frwullgalioa(DC1), Any carraimfl4slory Jaia mumbigme rhet bm%%alottainedhyllm DClmey berelesS mOou-M bylaw,
WaiverSYgnature: / 9("
Iowa CrLI/ nal Hxstox•y Record Check Results
As ofM 2'/0 �7 a search of the p,ovided name amd date of birth xer ealed;
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No Towa Ctimival T14story Record forlhd wi.th DCI
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7207 meinuviowadot.gov
.)MAPTERt I SIMPLZR I CUSTOMER ,,,daaaadr�—•
Inquiry Dafe: 9/25/2014
Name: Hamad, Magahed Mohamed
Alnaese
Address: 2659 ROEEP.7S RD APT 26
chy/state; IOWA :'Tyr IA 522462741
Railing Andress; 2654 ROBERTS RD AFI 21
Mailing CRY/State: IOWA CITY, IA 522462741
Convictions
Office of Driver Services
PO Box 92041 Des Mcllpie5, IA 50306-9-104
Pilune_ 515-244-9124 f 800-.532-1121 I Far 515-239-t$.37
vlwva.i0rrad0i:gDY
Certified Abstract of Driving Record
DL/ID>:
241AD4645(IA)
Customer V.
5400630
Class:
D
ID status:
None
Audit $:
7202303
DL Status:
VAL
Issue Data:
08/02/2013
CDL status;
None
Expiration Data;
08/0212018
CDL Cert Stature
None
Endorsements;
3
CDL Mea statues
None
Restri<Dorg:
NONE
Restricted
None
Date of Birth:
8/2/1980
Supplement:
Sex:
M
History Information
Emotion Date
- Conr,'ction Data �a
ACD Explanation
County
]DR
10/21/2011
12/04/2011
Improper Registration
then
IA
11,29/20]303/05/2013
_. _. .... .. ._......._ ._
S92 'Speed
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rlahnson
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Names Hamad, Mogahe0 Mohamed Alh Esse OL/IDI 241AD4645
Pursuant to Iowa Cade §321.10, 1, Kim Snook, Director of ORlce of psych Services, larva Department of Transportation, do hereby certify that I am the Wstodlan
or the records had by the Office of Driver ServlCes, that this is a true and accurate copy of an oNlcial record currently In the custody of said office, and that I have
been authorized by the Director cf the Iowa Department of transportation to so Certify
In witness whereof, I have caused my signature and the seal of the Department to Ed set upon thls document, at Ankeny, Iowa this date,
rr IOWA
D. 0. T.
Neste! Hamad, Mogati Mohamed Alhassa DL/ID: 241AD4645
985(2014
Offlce of Orlver Services
]owe Department of 7nansportat on
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