HomeMy WebLinkAbout12-005CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-SO40
(319) 356-5497 FAX
1. Name
2. Mailing
Authorization Number 1a—
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
3. Telephone: Home (5o�6j — oS O -S
4. Prior experience in transportation of passengers:
Other:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? _
Type of offense Where When
6. Have you be n convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?9
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? C3
Tvoe of offense Where When
8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? Aj C3
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) The re-
port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli-
cation.
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
derW idnvbadg 09/2010
I hereby certify that I have i sued to me by the Iowa Department of Transportation a valid Chauffeur's license number
�j O (1� . I understand that if I falsely answer any questions in this application, that this
application may be denied. I understand that if I falsely answer any of the questions in this application, that this application will
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 a license
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 { II I Z.
STATE OF IOWA )
COUNTY OF JOHNSON )
Lh
Subscribed and swom to before me by ��s�;�„ R� �aa�1�c��s rn1,�`,a� On this 1� day of
Notary Public i and for the State f lower—
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I have reviewed this application, DCI report, and the State certified driving record of this applicant and have deter-
mined that there is no information which would indicate that the issuance would be detrimental to the safety, health
or welfare of residents of the City of Iowa City (Title 5, Chapter 2, City Code).
Signa re of Policeor designee gnee Date
; l r e_ �- - // -
is
Signaltife of City Clerk or designee Date
After Police Chief and City Clerk have approved authorized taxi driver names will be placed on the city website at icgov.org.
Taxi cab businesses are required to provide Driver Identification cards.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
clan dmc WaW2010d 09/2010
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Div of Criminal Investigation
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No. 5483 P. 2/3
No, 196 1 r. L
STATE OF IOWA
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Received Time Dec -28. 2011 2:21PM No -4222
Iowa Department of Transportation
Office of Driver sefvices (Toll Free) B M1-532-1'121
PO Box 921W, Des Manes, IA 5930&92O4 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
12/27/2011
DL/ID #:
570AG6289 (IA)
Customer #:
5911203
Name:
Mohamed, Hatim
Class:
A
ID Status:
None
Ahmed Husseen
Address:
921 22ND AVE APT 8
Audit #:
5706289.
OL Status:
VAL
Issue Date:
12/27/2011
CDL Status:
SUR
City/State:
CORALVILLE, IA
Expiration
01/01/2016
CDL Cert
None
522411545
Date:
Status:
Endorsements:
NONE
CDL Med
None
Status:
Mailing Address:
PO BOX 5692
Restrictions:
NONE
Restriction
None
Date of Birth:
1/1/1973
Supplement:
Mailing City/State:
CORALVILLE, IA
Sex:
M
522410692
History Information
CLEAR DRIVING RECORD
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:
•% ,
12/27/2011
IOWA'"
).0.T.S.W
r S
DRIVER
Offices of Driver Services
Iowa Department of Transportation
Name: Mohamed, Hatim Ahmed Husseen DL/ID: 570AG6289