HomeMy WebLinkAbout12-059�r
CITY OF IOWA CITY
410 Last Washington Street
Iowa Ci ty, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
First
1. Name
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
Last
(Office Use Only)
2. Mailing Address!4�?QZ c ver Jc C, 'nY Q O�
3. Telephone: Home 7 1A - kA 2 lo Other: �7, r1
4. Prior experience in transportation of passengers: ? `j '�' C'A S
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 been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?
Type of Offense
Where
C—)
7. Have you been convicted of any traffic offenses in the last five years?
When
Tvoe of offense Where When
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)
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)
cleMtaxidrn&adg 09/2010
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
Z �-Si �t S Zk'7_ . 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 ti 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.
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STATE OF IOWA )
COUNTY OF JOHNSON ) 1 \ \ I
Subscribed and sworn to before me by \�s�amohgMQ� �ov �w, On this day of
aCi7_
in and for the
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).
Date
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
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Received Time Feb. 15, 2012 3:31PM No. 9359
3
n
Iowa Department of Transportation
Office Df Driver Services (Toll Free) WG-532-1121
PO Box 9204, Des MD nes it15U3I46 92U4 515-244-9124
1*0 FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
2/28/2012
DL/ID #:
713YY5282(IA)
Customer #:
435513
Name:
Moustafa, Hatem Mohamed
Class:
B
ID Status:
None
Address:
1803 GRANTWOOD DR
Audit #:
5104078
DL Status:
VAL
Issue Date:
03/23/2011
CDL Status:
VAL
City/State:
IOWA CITY, IA 522405959
Expiration Date:
04/23/2016
CDL Cert Status:
None
Endorsements:
P
CDL Med Status:
None
Mailing Address:
1803 GRANTWOOD DR
Restrictions:
Corrective Lenses, Vehicle
Restriction
None
without air brakes
Supplement:
Date of Birth:
4/23/1965
Mailing City/State:
IOWA CITY, IA 522405959
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Moustafa, Hatem Mohamed DL/ID: 713YY5282
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:
-o'�
2/28/2012
IOWA
). 0. T.,.Sey
I OBNEO S`=
Office of Driver Services
kn�
Iowa Department of Transportation
Name: Moustafa, Hatem Mohamed DL/ID: 713YY5282