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HomeMy WebLinkAbout16-012Ott, CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name (REQUIRED) . IDENTIFICATION NO. )(c-012— (Office Lc-0fZ(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 First 2. Address (REQUIRED) 2"\\a P e 1 Cil p 1 2X- I low,) 3. Contact Information (REQUIRED) Email: Cell Phone: �3 (`\) 1eU—`1Z1.3 (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) p 1 /,,? I /'%p "L -I b. Taxicab Business Name (REQUIRED) 9.J n '�:�Ai C9 --Q 5. Prior experience in transportation of passengers: 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? 10 a Type of offense Where When ��....,...; WX. What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other"N) Have you been arrested / charged with any traffic offenses in the last five years? — 4 Type ofcff'nse Where When p �PeAI 2oltA What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended ead Guil 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 provide the names) 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 hereby certify that I have issued to me by the Iowa Department of Transportatiop p valid Chauffeur's license number !o )iC3nt;l issued onol 001t, expiring on 0 I olZ . 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 STATE OF IOWA ) COUNTY OF JOHNSON ) Subscribed and sworn to before me by I+nf: nA_ h- H- tLlvkrAP 4_ep on this 12 day of '1 C.— 1, n!.. 20/1 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 0 ! Ad / /2o2 I Signature of P i lief orilef 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 ure�rk or designee L �21.2,e,'Aol D81e Office Use Only v� Approved application DCI report State certified driving record Website update ! ' r10 77 Clerk)(AXIDRIVBADGEAPPL92014amended DCC 03/2015 I Jan.13. 2016 1:33PM Dlv cf Crirnlnal Investigation FfaY !CILv 01 lOw6 Cliv Clark OIIICe 316 3666667 No. 5305 P, 2/3 .1112Jtole; 16:26 w3ce P.002/002 FpX IND STATE OF IOWA s /1s ( CheckI1 ... Request Form towa� sI` y� qy 11 To: folva Divislon of Crhninal Investigation Support Operations Hureou, V Floor 21$ F, 70' Strect Des Moiues, Iowa $0319 (515)725-6066 (515) 725.61100 Fax Last Name Me of Birth (mandalor 1/t J 1'713 First Name pCTAccoamlNunlber: t4Cp7'7 �F (if npplica Ic) From! City of Iowa CiEv ty Clerk's _ . CiOffice 410 L, tVashin tgon Street Iowa City, IA 52240 Phone: 319-356-5041 _ Fax: 319-356-5497 ,Male ©Temale AVxw,-L A Hiss-, T'f aivel' brfoi97eafioll: Wi Ihout a signed waiver from the subject of the request, a complete criminal history record may not be releasable, per Code of Iowa, Chapter 692,2, For complete eriminal histary retard information, a$ allowed by law, ahvays obtain n waiver slanature from the sublect of the reauest. Waiver Release: 1 hueby give permission Por the above requening ofcW m tondud en 6vo criminal hiamry Acord check with the D'n'ision of Criminal Lrvesligalion (DCIJ. Mgeriminal history Bala cnnccming me that i5 rnaielaiaed by the❑Cl ma)'be releg5ed as alloned by law. �<L A Waiver 2 Iowa Criminal History Record Check Results (DClaseOnly) As of r a search of the provided name and date of bh1h revealed: No Iowa Criminal History Record found with DCi ❑ Iowa Criminal ITistoly Record attached, DO N DCI inilials!�� DC) -77 (08/25110) Received Tire Jan.19. 9616 9:14PM No.593i Inquiry Date: Customer 4: Name: 1/12/2016 5911203 Pagel of 2 nnT %klvu'LAJ.It`lNca3dotgo Office of Drives Services FC: go, 9204 1 Des Moines IA 50306. 92 ,l Prix e ; 15 244-9124 1 82013-532-§ 121 ; Fa+: 51F239 -1,S37 w vt_iawadot aou Certified Abstract of Driving Record DL/ID #: 570AG6289 (IA) CDL Permit Class: None Class: A Mohamed, Hatim Ahmed Audit #: 9684181 Husseen Address: 2417 PETSEL PL UNIT 1 Issue Date: 01/05/2016 City/State: IOWA CITY, IA Expiration 01/01/2024 Date: Endorsements: NONE CDL Permit Issue None Date: COL Permit 522463609 Mailing 2417 PETSEL PL UNIT 1 Address: None Mailing IOWA CITY, IA City/State: 522463609 Date of 1/1/1973 Birth: NonE Sex: M Expiration 01/01/2024 Date: Endorsements: NONE CDL Permit Issue None Date: COL Permit None Expiration Date: Restriction None CDL Permit None Endorsements: CDL Permit CDL Permit None Restrictions: 3244024129 ID Status: NonE Restrictions: NONE DL Status: VAL Restriction None CDL Status: VAL Supplement: CDL Permit ELG 33079 Status: 3244024129 Medical Examiner Jurisdiction CDL Cert Status: Non -Excepted Interstate (319) 339-3921 CDL Med Status: Certified CDL Medical Examiner's Certificate Certificate Specifics _ Expi, n._;tions Medical Examiner First Name Ernest Medical Examiner Middle Name Manuel Medical Examiner Last Name Pence Medical Examiner License Number 33079 Medical Examiner National Registry Number 3244024129 Medical Examiner Jurisdiction IA Medical Examiner Phone (319) 339-3921 Medical Examiner Type Medical Doctor Medical Certificate Issued Date 01/28/2014 Medical Certificate Expiration Date 01/28/2016 Date Added to CDLIS Driving Record .01/05/2016 History Information Convictions Citation Date Convec Ion Dime ACD ^wxplanat€an County -. JUR 09/13/2014 30/01/2014 S92 Speed Johnson IA 11/29/2014 12/29/2014 S92 '.Speed Johnson 1A Accidents - Accident involvement indicated does NOT mean the individual was at fault or given a citation. 1/12/2016 Page 2 of 2 AccidInt Date 02/04/2015 _ Case RUY14p _ jure, .845242 _.. IA Name: Mohamed, Hatim Ahmed Husseen DL/ID: 570AG6289 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: :jI 1,r 1/12/2016 IOWA ' D. O. T.;�% %f""" Office Driver of Services Iowa Department of Transportation Name: Mohamed, Hatim Ahmed Husseen DL/ID: 570AG5289 1/12/2016