HomeMy WebLinkAbout16-241i �III1y9lp�
CITY OF IOWA CITY
410 East Washington Streel
Iowa City, Iowa S2240-1826
(3 19) 356-S040
(3 19) 356-5497 FAX
1. Name (REQUIRED) _
2. Address (REQUIRED)
IDENTIFICATION NO.
-ayl
(Office Use Only)
APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER
(Police Department review must be made between S a.m. to 3 p.m., Monday - Friday)
Failure to complete the "required" information will result in denial of the application
First
3. Contact Information (REQUIRED) Email:
(All
4a. Driver's License expiration date (REQUIRED) 0 1S/G
b. Taxicab Business Name (REQUIRED) A ty&p"/CGt
5. Prior experience in transportation of passengers:
Middle
Last
54-1 aIya
oUA C-71.1 7-,4 5-z z
-Ha/Wa t°"hO&Vditell Phone: S12 S -!y 2T /KT
unication sent via email)
6. Have you ever been arrested/ charged with any misdemeanors and/or felonies in this State or elsewhere? / V U
Type of offense
W here
When
What happened to the charge? (Circle one)
Convicted Dismissed _ DjaWrr-ed Suspended Plead Guilty Other
7. Have you been arrested /'charged with any traffic offenses in the last five years
Type of offense Where When
Si7�Po� ,
14 .,7 sc /Z, n ! 7ci Z l
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
When
9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide the name(s)
A/ b
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE CERTIFIED
DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIEF REVION
You must apply for an individual Department of Criminal Investigation Report (form available upon request).
(SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY)
07/2016
APPLICATION FOR TAXICAB VEHICLE DRIVER
Page 2
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Driver's license number
Z viissued on o 4/1 ?-/ / /, expiring on oF$/o Z/ / N . 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./o/z / //L
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by ICl5rnl.� NmKt, a d0 on this Z) day of
Public in Ad for the State of
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 Driver's license 6�Z/10_44
Signature of Police Chief 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.
Signht,ure of City Clerk or designee
1 911�16% l /�o
Date
r.�
Office Use Only
-- CV
Approved application
DCI report
State certified driving record
Website update
Clerk/rAXIMNBADGEAPPL92014 mended DOC 0712016
Oct.19. 2016 2;36PM Div of Criminal Investigation @o. 5 /4 1 F. 2/2
From:C11y or IOWA City Clark Otrlco 31B 3666,197 10/14/2016 17:11 0716 V.002/002
STATE Off( IOWA
1 a
9k
Criminal Mkory Record Check
1 .
S�
yd rY
To: tot+a Division of Criminal lnvcsfigatlon
8nppori Operatious Bureau, t" Floor
215 E. 7" Street
Des muincs, lowa 50319
(315) 725.6066
(515)72.5-6080 Fax
Last Name (mandato
Date of Birth n,,...e
On:
0
bCl Account
(ifnpplisnbic)
Froin' (`If � Ilf laeya C(Iy
City Clerltas Office
410I_. 1 ashington circL(
[01vaC)ty, IA 52240
Phone: 319-356-5041
Fax: 319-3565497
a I Di( ale of emale
e
�AtILI&d
wamer l/tjararaft0ll: Wif lout a signed waiver front the subject of the request, a complete criminal history record may not
be releasable, per Code of lows, Chapter 692.2. For eomuletc criminal history record information, as allowed by law, ahvays
obtain a waiver simature from the snhinni of ahP rnn...er
blralver, Release; I hereby give prnnission for the above requesting of ficial to conduct m lovea criminal history record check with rhe Division ofCriminal
hrvrs1198tion(DC1). Any criminal history data conceming me that is maintained by rhe DU may be roleased as alloveed by law.
Waiver signatfsre:
ase only)
As of
—194W -1k, a search of the provided name and daie of birth revealed: r�
CJ
No Iowa Criminal history Record found with DC1
Iowa Criminal History Record attached, DCI # --
._—..—_—�—, i ,-, ..J
DCl initials__ (;
11CL77 (08/25/10) �-- —-----�—'--� c-.,' —'�--
v
fler-eived Time Oct, 14. 9016 4,53PM No. 6174
a}
C,J10WA00T www.iowadot.gov
SMARTER I SIMPLER I CUSTOMER DRIVEN g
Ofice of Driver Services
PO Box 9204 1 Des Moines, IA 50306-9284
Phone: 515-244-9124 1 8OD-532-1121 1 Fax: 515-239-1837
www-kmadot.gov
Certified Abstract of Driving Record
Inquiry Date:
10/21/2016
Expiration Date:
DL/ID #:
241AD4645 (IA)
Customer #:
5400638
Class:
D
Name:
Hamad, Mogahed Mohamed
Audit #:
9928089
DL Status:
Alhassa
CDL Status:
None
CDL Permit Status:
Address:
2654 ROBERTS
RD APT 2B
Issue Date:
04/12/2016
Expiration Date:
08/02/2018
City/State:
IOWA CITY, IA
522462741
Endorsements:
3
Mailing
2654 ROBERTS
RD APT 2B
Restrictions:
NONE
Address:
Restriction
None
Mailing
IOWA CITY, IA
522462741
Supplement:
City/State:
Date of Birth: 8/2/1980
Sex: M
History Information
Convictions
CDL Permit Class: None
CDL Permit Issue None
Date:
CDL Permit
None
Expiration Date:
CDL Permit
None
Endorsements:
CDL Permit
None
Restrictions:
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Permit Status:
ELG
CDL Cert Status: None
CDL Med Status: None
Citation Date Conviction Date ACD Explanation County IUR
01/29/2013 ''103/05/2013 IS92 Speed Johnson IA
Name: Hamad, Mogahed Mohamed Alhassa DL/ID: 241AD4645
Pursuant to Iowa Code §321.10, I, Melissa Spiegel, 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: Hamad, Mogahed Mohamed Alhassa DL/ID: 241AD4645
14,
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IOWA
10/21/2016
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Services
OBIVEA.f=
Iowa DepartmeMof ortation
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Name: Hamad, Mogahed Mohamed Alhassa DL/ID: 241AD4645