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Home My WebLink About15-1361 � 1 CITY OF IOWA CITY 410 East Washington Street Iowa City. Iowa 52240-1826 1319) 356-5040 (319) 356-5497 FAX IDENTIFICATION NO ►5-) 3l (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) Failure to complete the "required" information will result in denial of the application Firstr� Middle Last 1. Name (REQUIRED) L'L / HCl :'i /1/4 OA 2. Address (REQUIRE[)) _7 ^C7St f(G�II 3. Contact Information (REQUIRED) Email: C,, .0-I Cell Phone (All written communi etion sent via email) 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) 5. Prior experience in transportation of passengers: i/ •ct:m & 7 Y I 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? /UO Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 7. Have you been arrested / charged with any traffic offenses in the last five years? � -1 n Type of offense Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? A/(2 Type of offense Where When 9. 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 STATE 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). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 0212015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I he reb+�certif� that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number �L(O�(;� jf Q {'4i l issued on r'/ v6 expiring on 0I u°! X0(7 1 understand that if I falsely answer any questions in this application, that this application may be denied, agr e 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 L(L//Ji _ Date 0� 5 STATE OF IOWA ) COUNTY OF JOHNSON ) Sub srb C d and sworn to before me by 1 4zlr� �G S� on this day of LIJ. �C� I �� r'(r I '- �vawts KFLLI�� ... �.. . i� . Li �C�Ca e ,r „ :n :umber 221819 Notary Public in and for the State of Iowa I 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 Cjt�,of Iowa City (Title 5, Chapter 2, City Code). Chau_eur's license I Z Z 201 T designee 771 �/ /s_ t 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. %t �..�LLr Sig�ure of City Clerk or designee Office Use Only Approved application DCI report State certified driving record Website update 01erkrrA%IORN9ADGE PLU014amended.DOC 03/2015 DVe 01erkrrA%IORN9ADGE PLU014amended.DOC 03/2015 Ju1. 1. 2015 2 : 4 5 P M Div of Criminal invest igation No.0123 P. 2/2 Fr. ... .--y — town �. r,y Clem vrr.cn P.003/003 :. STATE OF KIWA OxPu'v COn"iRa�( Hiscary Record Check Ite€uet Faral I -o: Iowa Divisiun of Criminal Llvesliga2ion Support Operations BnI eau, 1" 1100, 215 E. 7" Strue I Des Moiues, coma 50319 (515) 925-6066 (515) 725•(.080 ra> I. alit recivesting an A/145514/I/ DBCC Uf 1'il]'th (mandalm First ]Name 51-Tou.M ))CI ACC6MI1 Natnbcr: -Ma- (if applic Ale) From: City of Iowa Cita City Clerlt'6 Office-__________..__._,.._ 410 C. WaslitLit Ljj 6trcct fame 411L,, IA $'1240.-------�---- Phonic: 319-356-5041 _ rax; 319 35 -6.5497' H/ aAK Social Seeurita, Number ] MAIC ❑7,+emale 1731r _ ( r _ Waiver Ir7forula1[JA! Without a signed waiver from the 9 i bi Lef of lite request, a complete eriminaI history record may aot be t•eleasoble, per Code of town, Chap(er 692.2, For cam le[e criminal history record information, as allowed by law, ahrays Obtain a waiver signature from thesuhinrt of the ti•nnunor )'l'17i"F RelCaseI hereby give perniiSsion farlh, above ragoCslingoffrcial to condo Cl en 10Wa cdminel IIISleryrecOM vhech Will11ht Division of Criminal Invosligalim� (DCI). My erhninal hislnqdale calaming ale Ilial is maintained Ay the llC1 mq' be releosed as allowed by Ian. Waiver Siglralfire: 10YA'a Criminal History Record Check Resents (UGI nsc only) of —. 1 /I�-, a search of the provided Mame and dale of'birih reveftfKi- — .0As U..•... N0 lot"•a (:rimi»al History Record found with [)C1 � v ` �+l iott'a Criminal llisWnv Record attached, U(') J__r_ rXI initials___ _ DCI -77 (08/25110) Received Time Jun.29, 2015 2:35PM No 1825 C4iUWA00T SMARTB I SOMPLEEt I (USTOME DRIVEN UaflifiV tCDW [�Ot. t1V Inquiry Date: 7/8/2015 Name: Hassan, Eltoum Hagar Address: 724 FOSTER RD City/State: IOWA CITY, IA 522451596 Mailing Address: 724 F05TER RD Mailing City/State: IOWA CITY, IA 522451596 Name: Hassan, Eltoum Hagar DL/ID: 623AH8178 Office of Driver Services PO Eox 9204 y Des Moines, 1A 5i)3176 -920A Pham..': 515-244-9124 1 800-582-1121 ( Fax.: 515-229-1837 W*w.iowadoLoov Certified Abstract of Driving Record DL/ID #: 623AH8178 (IA) Class: D Audit #: 7505904 Issue Date: 11/06/2013 Expiration Date: 01/01/2017 Endorsements: 3 Restrictions: NONE Date of Birth: 1/1/1965 Sex: M History Information CLEAR DRIVING RECORD Customer #: 6009173 ID Status: None DL Status: VAL CDL Status: None CDL Cert Status: None CDL Med Status: None Restriction None Supplement: 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: p:.......,7ifi� .' 7/8/2015 IOWA nA D. O. T. e: Office of Driver Services Iowa Department of Transportation Name: Hassan, Eltoum Hagar OL/ID: 623AH8178