HomeMy WebLinkAbout15-1721 A i
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CITY OF IOWA CITY
410 East Washington Street
Iowa City. lo5ia 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1, Name (REQUIRED) _
2. Address (REQUIRED)
3. Contact Information (R
IDENTIFICATION NO. k5— — ) %d
(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
4a. Chauffeur's License expiration date (REQUIRED) 1122 f I
b. Taxicab Business Name (REQUIRED) _ me(f f ?5v, e
5. Prior experience in transportation of passengers: _ 2 y{ ons
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? " 0
Type of offense
What happened to the charge? (Circle one)
Where
Convicted Dismissed Deferred Suspended Plead Guilty
7. Have you been arrested / charged with any traffic offenses in the last five years?
Type of offense
What happened to the charge? (Circle one)
Where
When
Other
L)
When When
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? ixf 0
Type of offense
Where
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provyl the na�e(s)
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE Cl
You must apply for an individual Department of Criminal Investigation Report (form avai
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
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M
02/2015
rG
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that 1 have issued to me by the Iowa Dep rtent of Transportation a val d Chauffeur's license number
Q '2 Lj A � 7`1 �0 issued on 0 j Z expiring on 22 16 1 . 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 02
STATE OF IOWA )
COUNTY OF JOHNSON ) j ' ! r�
scribed and sworn to before me by AI`�Q.r 4-c1)'-c� on this "'I� day of
aDIS 1J "��
..._ a I ELLIE K. TUTrLELA.r-[,"
L y sf r mml a '« fib E p reNo ary 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 City of Iowa City (Title 5, Chapter 2, City Code). {
Expiration date of Chauffeur's ' ense 9 J Z' -z-
q2-
/ 7
q2- y
Si nature of Police Chie desi fl 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.
Signature of City Clerk or designee
s a,
D to
Office Use Only
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Approved application
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DCI report
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State certified driving record
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Website update
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Clete MIDRIV& DGEHPPL92014amended.DOC
03/2015
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Prom:Cl[y of lowe Chy Clerk OHlac 319 26e6497 05/11/2015 Oe:03 #l99 P,0021002
SATE OF IOWA
CrirninA History Record Check
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Tv; lowa Wvision (IrCrrnlinal1nct€iigalion
Support opCl'aiiml$ tau roan, 1" E'loor
215 E. 7" Street
13tH Moines, So>114 50319
(515)725.6066
(515) 725-6090 COX
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DCA Aceoiiw Minibcr:
(if applicable)
City Clerlds ofriee--
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Iowa Cilv, IA 52240
Phone: 319_3465041
Fax: 319-356.5497
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Waiver Information. Without a signed waiver from the subject of the request, a complete criminal history record may 1101
be releasable, per Code Of IOWA, Chapter 692.2, For complete criminal history record information, as allowed by law, always
_oblain a n'Alver si P'9efnr9 fen. it.. ool.lnnr ..r'%—
Waiver Rdeasel 1 htreby giyc pennissiwt for II'e aEoyc rcqutsliag ollicial 10 condyq M IOWA criminal hi far
111veSfi mi DC s fcd by d ehecF, wisp the DiviSimt ofG'riminal
g oil ( If, Any Climina) h15101)' dela wn4n1h1$ nit 11181 is mainlapl IIIc 11Cl may be released ) S e5 e119trcd by 1011'.
WaiverSrgnature:—__/
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govt -a Crillzi11a1 �istot•y �iecnr� check Itesutt� �
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1� � ___, a search of the provided name and dale of bhih revealed^,
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No Iowa Crit»;nal Histcu'y Record found wit11 UC'1
knva Crinunal
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History Record attached, DO 11
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DC) -77(0V/25/10)
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SMARTER I INTI -F I CU<,TOL'IEF DRIt,EN WiPJkvlowc' dot.gov
Office of Driver Services
PO Bas 9204 Des Moines. 1.4 59306-9204
Phone. 515-244-91241800-5.32-1t2l IFay -.515-239-1837
www .iowadat,gol,
Certified Abstract of Driving Record
Inquiry Date:
8/11/2015
DL/ID #:
424AF7780 (IA)
Customer #:
5612537
Name:
Hamad, Amar Hamad
Class:
D
ID Status:
None
Yt►
Mohamed
Address:
2420 BARTELT RD APT 2D
Audit #:
5845747
DL Status:
VAL
Issue Date:
03/09/2012
CDL Status:
None
City/State:
IOWA CITY, IA 522462707
Expiration Date:
11/22/2015
CDL Cert Status:
None
Endorsements:
3
CDL Med Status:
None
Mailing Address:
2420 BARTELT RD APT 2D
Restrictions:
NONE
Restriction
None
Date of Birth:
11/22/1965
Supplement:
Mailing City/State:
IOWA CITY, IA 522462707
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Hamad, Amar Hamad Mohamed DL/ID: 424AF7780
Pursuant to Iowa Code 3321.10, 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:
-oiy4
8/11/2015
IOWA'
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Office of Driver Services
Yt►
Iowa Department of Transportation
Name: Hamad, Amar Hamad Mohamed DL/ID: 424AF7780