HomeMy WebLinkAbout15-262tiWlll
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
1. Name (REQUIRED) -
2. Address (REQUIRED)
IDENTIFICATION NO. / 5-- Zls1�
(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
3. Contact Information (REQUIRED) Email: sitat't)e Jrj @ LjnkrC,2,1
(Ali written communication sent via email)
4a. Chauffeur's License expiration date (REQUIRED)
b. Taxicab Business Name (REQUIRED) --AmOrl /j
7 AI ,
-LL 64
5. Prior experience in transportation of passengers:
Last
Phone: _�% -/-Qj�j.._ 3 W,D
6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? i m
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
Have you been arrested / charged with any traffic offenses in the last five years? ^f
Type of offense
What happened to the charge? (Circle one)
Where
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?
Type of offense
Where
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please prowde'the m*ne(s
C�
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIEND
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REjgW
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 her certify,th t I have issu d to me by the Iowa De rtment of Transportation ,valid�Chauffeur's license number
issued on expiring on Y�6�08 /,217/ q I understand that if I
falsely answer'any questions in this application, that this ap lication may be denied. I agrbe 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 6 ' S–
r ---
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STATE OF IOWA )
COUNTY OF JOHNSON ) AA 7� k
rbscribe and sworn to before me by %D 6d ti L L I CiSSe n on this � r day of
l I)
K. TUTTLE I Notary Public in 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).
Expiratio dot Cha feur's license.
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— Ore of City Clerk or designee
L)Ate
CJ
Office Use Only
M C-) x
Approved application
DCI report
State certified driving record 1'.;
Website update try
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Clerk TAXIDRIVBADGEAPFL92014amended.DOC
03/2015
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OfaCe of Driver Services
PO Br3l ii2i)4 i Das Maines. iA 60306 3204
Phuu e. 515-244-912."+ ( Wfl-'_.32-1121 I Fara_ 515-239-IP37
Ww3v. iaa'adatgov
Certified Abstract of Driving Record
Inquiry Date:
10/9/2015
DL/ID #:
789AK7776(IA)
Customer #:
6203841
Class:
B
Name:
EI Hassan, Salah Hassan Bestir
Audit #:
9431924
Address:
1076 CHAMBERLAIN DR
Issue Date:
09/18/2015
ID Status:
None
Expiration Date:
06/08/2019
City/State:
IOWA CITY, IA 522402952
Endorsements:
PS
Mailing
1076 CHAMBERLAIN DR
Restrictions:
Automatic Transmission, No
Address:
Manual Transmission Equipped
CMV, No Class A Passenger
Vehicle
Restriction
None
Mailing
IOWA CM, IA 522402952
Supplement:
City/State:
Date of Birth:
6/8/1973
Sex:
M
CDL Medical Examiner's Certificate
COL Permit Class:
None
CDL Permit Issue Date:
None
CDL Permit Expiration
None
Date:
C–) ° 5
CDL Permit
None
Endorsements:
8795856463
CDL Permit
None
Restrictions:
(319) 356-3335
ID Status:
None
DL Status:
VAL
CDL Status:
CDL Permit Status:
CDL Cert Status:
CDL Med Status:
VAL
ELG
Non -Excepted Interstate
Certified
Cer-tiricatk speciTlCS
Expianabon,
Medical Examiner First Name
Claudia
Medical Examiner Middle Name
Lynn
....Corwin
Medical Examiner Last Name
-
C–) ° 5
Medical Examiner License Number
.29261
Medical Examiner National Registry Number
8795856463
Medical Examiner lunsdlction
'IA
Medical Examiner Phone
(319) 356-3335
Medical Examiner Type
Medical Doctor
Medical Certificate Issued Date
08/12/2015
Medical Certificate Explrabon Date
08/12/2016
Date Added to CDLIS Driving Record
'.09/18/2015
History Information
CLEAR DRIVING RECORD
Name: EI Hassan, Salah Hassan Bestir Dll 789AK7776
Pursuant to Iowa Code §321,10, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do.hereby
cel'ef 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 eilsto
of d5d offcsi that I have been
authorized by the Director of the Iowa Department of Transportation to so certify.
C–) ° 5
—I ..,...,....
In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Ioi0tfil§datP.
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STATE (IF TOWA.
('-'I•ilni€ial Hisfol-y Record Ci eej(
Requesi Form
1)(3 Account IVmnber: `'1 i)Da — F
I(JVA Division of CXimigdl lnvesll latibtl
6 Frani: City of Inwe C_ ,tw
Gupry01'I OperationA flureao, 1"' 1;Inor _
215 L. 71" street City Cler i' E>f FCC
Cies Moines; lowu 50319 410 E. Washiu ton Etrect w _
(515)'/25.6(166
( f�?2Ps-G 680 Rax Jt,
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1'houe: 319-398-5041
Rax: 319-356.5497
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hGrriver IJIfOryfr¢rtfl07i: Wi(hon{ a signed waiver frons the subject of the requesl,�criminal Wwry record may not
be releasable, per Code of Iowa, Chapter 692.2. X:or complele criminal history record information, as allowed by law, always
obtain a waiver si nsture from the subject of the rfioucsf.
Ii/a[Ver Release. I hereby give pennission for rhe above requaning official so condocl m lona a urinal history Word cheep, with the Uicision of Criminal
Inves4igasiwllDC1). Any rriminal hiss Dry data wnceming me 11134 is onBl"Wioed by Ills DO may be released as Wowed by law.
R/anter sigrttdfrre:
1OLVa Cr, RiCO1`C} CY1eCY� ��S@FYf9
�fA�L'I ups pulp)
AS Of
searoll of the provided name and date of birth
rel ealed
n`f
CD
nr,
No Iowa,
C.'riminal 1-lislory Record found 1�'ith UCl
,
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t
town C' h111341 19istury Record atlached, )C) l#
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DCI -77 (OR/25/IU)
RerPivPd Time (1rl 19 9015 10 '11AN i\n 9Q19