HomeMy WebLinkAbout15-231l
CITY OF IOWA CITY
410 East Washington Streel
Iowa City. Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
IDENTIFICATION NO. ) 5',j 3
(Office Use Only)
—?/FIPLo
APPLICATION FOR TAXICAB I MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday)
Failtne to complete the ' to ulred" information will result in denial of the application
First r Middle Last
1. Name (REQUIRED) U 1 Litt M L7.9 OAR h�tssA/u
2 Address (RECUIRl � � /"05 tL1— t<�GlII �/
3. Contact Information,' Email: �!�r`oLGx�rh- Jla• tt o•'te% Cell Phone 'y7-ZS3-�. 6n
(All written Commune ation sent via email)
Aa. Cl License expiration date (REQUiKtD)e)110 l A U
b. Taxicab Business Name (REQUIRED) 1 CGT
i
5. Prior experience in transportation of passengers:
6 Have you ever been arrested I charged with any misdemeanors and/or felonies in this State or elsewhere?
Type of offense
What happened to the charge? (Circle one)
Where
When
Convicted Dismissed Deferred Suspended Plead Guilty Other
7. Have you been arrested/ charged with any traffic offenses in the last five years?
Type of offense Where
What happened to the charge? (Circle one)
Convicted Dismissed Deferred
When
Suspended Plead Guilty Other
S 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 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)
02/2015
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby cert if� that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
issued oil v6 ' expiring on 0 f u l y D [ 7 E understand twat iF l
falsely answer any questions in this application, that this ap ligation may be denied. I 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
dee1ument8 relating to this application, and I further agree that, 0 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)
Signah.re of Applicant� fil//I " _ Date
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STATE Of IOWA )
COUNTY OF JOHNSON )
S ed and sworn to before me by C �y� 7 SS G� ^ on this
orday of
aia KI=LLI�F -
;T" r 4 Notary Public in and for the State of Iowa
umber 221819
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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 orwelfare of resi-
dents of the Cj4_of Iowa City (Title 5, Chapter 2, City Code).
license/,20` T
designee
7 f s-
Dat6
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 ure of City Clerk or designee
7
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
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STATE OF 10MIA
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Criminal His(€)ry Flee(jrd t".hnke, Request Form
fr,; town Divisiun of Crlarinal Investigation
Suppori Operations Bureau, I"lrloov
2I S Y. 7" st1 el l
Des hil6m, iovra 50319
(515) 925.6066
(515) 725•u080 Fax
Lam requesting an Iotas Criltainal History Record CJleck ml:
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10m 01Y, lA 51240
Pkotw 319-356-5041
Fax, 319-356.5497
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6Gaiver Infurnrrfrion! iVHhaal a signed waiver from the subj ref al the reglrest, a conmple(e criminal history record muy not
be roteasabit, per Code of lava, Chapier 692.2, For corn lefe criminal history record. infonnallon, as atimed 63law, ahrays
obtain aobtaio a waiver signature from tile subject of the rc9uest.
l�r((1VCY RCJCRSC� I hereby gine perini5siea for the shove mgllprlinq OfFeial to oa,ducl an Io P'S aAminnl Itlslnryremrtl ChleN w{It IhE Division nlCrimindl
lnvesligalimr (DCq. (uqernninal Lislnrydale ealrtming me ll�lmitym�aiulaiueu Ay the llCl mey be reb�s.,i hs 2howed by lax•,
Waiver Signaivre:
r Iowa Criminal History Record Check Results~—
l�Gl use only)
As of a search of the provided name and dale of birth rO'CA6r
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Iowa Criwinal ilistoyy Record attached, DCI K
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Dei initials__ /L._
DCI -77 (0812P1 0)
Received Time Ju6.29. 2015 2.35PM No.1N25
kuou4,ok OOT Wwv,0wedot.gov
Office of Driv Af Services
Pa Ebk 02DA C>Es Maines. to 50305-8104
phet�:p'-a1 _F-?4A-9i2a � 800-E_t�_i t"zt (Far' 515-238-783i
N'.Yw.FO1J3dCS:gOY
Inquiry Date: 7/8/2015
Name: Hassan, Eltcum Hagar
Address: 724 FOSTER RD
City/State: IOWA CITY, IA 522451596
Mailing Address: 724 FOSTER RD
Mailing City/State: IOWA CITY, IA 522451596
Name: Hassan, Eltoum Hagar DL/ID: 623AH8178
Certified Abstract of Driving Record
DL/ID #:
623AH8178 (IA)
Customer #:
6009173
class:
D
ID Status:
None.
Audit #:
7505904
DL Status:
VAL
Issue Date:
11/06/2013
CDL Status:
None
Expiration Date:
0110112017
CDL Cert Status:
None
Endorsements:
3
CDL Med Status:
None
Restrictions:
NONE
Restriction
None
Date of Hirth:
1/1/1965
Supplement:
Sex:
M
History Information
CLEAR DRIVING RECORD
pursuant to Iowa Code §321 10, I, Kim Snook, Director of Office of Driver 5ervlces, Iowa Department of Transportatlor, do hereby certify that I am the
custodian of the records III 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, Eltoum Hagar DL/ID: 623AH8178
7/8/2015
Office of Driver services
Mmp vim`-
Iowa Department of Transportation
Name: Hassan, Eltoum Hagar DL/ID: 623AH8178