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Home My WebLink About15-175a1 r 1 3� �IIIMtp� r Aw IN CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (319) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) _ 2. Address (REQUIRED) IDENTIFICATION NO I5-1?5 (Office Use Only) APPLICATION FOR TAXICAB 1 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 First Middle Last Q 3 X0 wl ,1 �a trr� v+e��c 0 C`A &4v iT A 5DQ4.6 3. Contact information (REQUIRED) Email: r,%17aS�.n 15 �Gr ti (-C� Cell Phone: 3t -3%N' IbbS (All written communication sent via email) 4a Chauffeur's License expiration date (REQUIRED) D/ /it b b. Taxicab Business Name (REQUIRED) C + ( cc, t3 5. Prior experience in transportation of passengers: i wti S 0 Y nv<, S � ti Cc 6 0Ir i✓y 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Where What happened to the charge? (Circle one) When Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? Type of offense Where When yJk,w L4- hit 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? Type of offense Where 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please pr(Fvf MQ 7 � n Q'I �.. 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) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation_ a valid Chauffeur's license number D h 1 DI) �d �µ issued on 3) 9 1 l expiring on I i;d /I -� . 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_ ` Date La 1 i 5 STATE OF IOWA ) COUNTYOFJOHNSON ) Subscribed and sworn to before me by f 1A p\ , LLA n ,tA, HQ- S �o A on this _ day of 1. _ r 1NENDY S. MAYER and for the State 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 City of Iowa City (Title 5, Chapter 2, City Code). Expiration date of Chauffeur's license - Signature ice C ief or designee 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. Signa .of City Clerk or designee </ai//,s D Office Use Only , Approved application DCI report State certified driving record — Website update ,-,� <T _. ru yq cs: CIeB( MDRIVHADGE PPl52074a ded DOC 03/2015 vuii, vIv c'i VI1.I11uai ,n v;', I,nl I V I mu.LV77 i. 't/I Frn, n�;Glty of Iowa Clty Olerk r, if lcc 310 366649 09/11/20115 08:20 W2o0 P.002/002 011STA TE OF I 01VA 1 Crimival History record C6tecti Requegt Form 7b, Iowa Division of Criminal Invesligatiul Support Operations ))u -eau, I,, Floor 218 );. 7" Strcel Des Moines, Iowa 511319 (515) 725-6066 (415) 725.6080 Cas 1 alit reglleSlinP an IOWA. Criminal Rrrn.d 0)—v r.., DN Acenun( llumbe); Clce 3 rram: City Uf to s'a Cify __w City Cler109 office 410 L Washington Street - lgwa City, IA 52240 ,--- ---- Phone 319-356-SO41 Fnk: 319-356.9497 � �— Last Name (mandatory) First Name 01and6106) _ ^� Middle Name (rtwmmtnaed) HASSAN MOP�� Date of Birth (mandatory) Gender Social Security Number bernommenat ) r(�(mandalory) WaiverAfornweion: Without a signed waiver from the subject of the request, a complete criminal llis(ory record may U01 be releasflble, per Code of Iowa, Chapter 692.2. For co- mnle!e criminal history record information, as allowed by Iaw, almays obtainobtaira armature from the subicel of the request. Waiver Reieitse: 1llemby eiee 1—isSion to, llte above requesling official to conduct an Iowa triminal I,M01y record Bleck nrilh the Division ofCrimiavl I11VesligeIion (DCI), Any triminal history dal? canccnrina me 11111 1$ mainlained by rhe DCI maybe relcosed as a) lowed by lew, WrriverSisyraqfru'c:_----�—___� Iowa iCCriminal history Record Check Results � j1>�I11$Zn ly a search Df the provided Dante and dale of birth revealed= No Iolva Criminal History Record found with UC:] - 10wa Criminal 1-lislory Record auached, DCI iJ Del initials ! `n I)Cl-77 (08/25/10) 6 _.....1 T:_. A... 11 1AIC n. 1r AIA 11.. 9C 69 4lUWADOT wvAliviowadotgov S^,';A RTEK I=;il I CUSTOMER DRI'VT I -_ Office of Drl Services PO Box 6204 , Dos Moines, EA 51306-q204 Phoney E15-244-9124 i 800-532-1421 p Fax 5155123.9-1837 www.icxvadot:oov Inquiry Date: 8/19/2015 Name: Hassan, Mohamad Awad Address: 2769 WHISPERING 11/23/2010 MEADOW DR City/State: IOWA CITY, IA 04/21/2012 522406847 Mailing Address: 2769 WHISPERING MEADOW DR Mailing City/State: IOWA CITY, IA 522406847 Convictions Certified Abstract of Driving Record DL/ID V: 261DD7091 (IA) Class: D Audit 7t: 7921154 Issue Date: 03/26/2014 Expiration 01/16/2017 Date: Endorsements: 3 Restrictions: NONE Date of Birth: 1/16/1986 Sex: M History Information Customer it: 4640700 ID Status: None DL Status: VAL CDL Status: None CDL Cert None Status: CDL Med Status: None Restriction None Supplement: Ut-Mon Detc Cenvfct€on Date '.CD Enplanatian Court•-, "UP, 09/25/2010 11/23/2010 S92 Speed (10 mph & under in 35-55 mph zone) Johnson IA 04/21/2012 07/13/2012 M14 fail to Obey Traffic Sign/Signal Johnson IA 06/11/2013 07/10/2013 S93 Speed IL Name: Hassan, Mohamad Awad DL/ID: 261DD7091 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: Name: Hassan, Mohamad Awad DL/ID: 261DD7091 8/19/2015 =YKV-V a Office of Driver Services Iowa Department of Transportation