HomeMy WebLinkAbout12-151�tIII
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(3 19) 356-5040
(319) 356-5497 FAX
First
1. Name
Authorization Number / a -/5
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday - Friday.)
NA
Last
(Office Use Only)
2. Mailing Address
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3. Telephone: Home
Other:
t`l-
30`11 - fAl'tC
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
YPe;f'j :�a &g /
Cu�L do oh�P ir.•�C Sion 5� �4-/al� Ia
Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
Tvpe of Offense
Where
Have you been convicted of any traffic offenses in the last five years?
Type of offense
Where
When
When
8. Has your drivers 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)
GerkRaxiarivbetlg
09/2010
I hereby certiy that ],have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number
I understand that if I falsely answer any questions in this application, that this
ap�cation 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 &�- C)3— 1 a
STATE OF IOWA )
COUNTY OF JOHNSON
bscribed and swo to before me bySIL'w1 . On this t day of
KELLIE K. TUTTLE (- t L. Cl
.. 't. _ .__.__ .._ ...ew neo In}on, Diihlin in nnrl fnr }ho Cfnfc of Inu,o
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).
Si na ure of Police ief or designee U Date
Sign a of City Clerk or designee Ddte
NOT VALID UNTIL Police Chief City Clerk have approved and authorized taxi driver names 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
dWkAMdddVbad ea M10.d 09/2010
A 1. 2012 4:09PMDiv of Criminal Investigation No.6698 PP.�1
V. LV IL f 14rm cI ly VIIIK �I ty V� luxa vi ty NV. Lv'tr
STATE OF IOWA
criminal History Record Check
Requ6st Form
DCILl000untNamber; Oona
' (ieappurama)
Tot Iowa Division of Crftninel Dvasilgation From: CITY OH IOWA CITY
Support oporptlons )3urenu, I"Floor CITY CYJ)MK'S OFx'ICE
215 D, 7rb Street 410 ):, WASXIINOTON STREET
)Des Molnar, reWA 50319
(615) 729.6066 IOWA CXTY IOWA 52240
(515)725-6080 rfax
Fhofte: 319.756.5041
Fax: 319-3564497
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Last NAMB
n_
LastNAMB mendelo
First Name (mandatorA
Middle Name remmmended)
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14WA 0
Date of Birth (n,andatoay
Gender (mendetoty)
Social Security Number emmmoneoa
Ud111silo OFomalo
d—! " Q q— oS
Malvel'.h'7forntarim: Without a signed waiver 1Yom the SAJoct of the request, a complete criminal history record may not
be releasable, per Code of Iowa, Chup for 691.2. For com leto criminal history record infonnadon, as allowed by laW, slWays
obtninawafversl natureiromthesubectofthere nest,
WYWWAI ECCUSe! lherebygipe pcnuresion for Ute abovavcqueating oalolat to wnduot an Iowa criminal History rcmfd o1x*whb Uto Dlvlslon 6M)m1nal
Jnvestigallon (DCL). My criminalbiatary data mncemingnla [Gana maintained by the llCl maybareleQaed a9 allowed by law.
Q Iowa Criminal History Record Check Results (DCluaoouty)
As of a search of the provided name and date of birth revealed;
�Q No Iowa glminal History Record found with DCI
Iowa Criminal History Record attached, DCI#
DCI inilia]
De,.e:,.A Ti,aavI..I an fe90fI d•idPM Nn 0497
Iowa Department of Transportation
Office of Driver Services (%91 Free) 8D-532-1721
PO Box 9204, Des Moines, JA 50306-9204 515-244-91244
FAX: 515-239-1837
Inquiry Date: 8/2/2012
Name: Hassan, Mohamad Awad
Address: 2422 BARTELT RD APT 2A
'Ile: IOWA CITY, IA 522462708
!Mailing Address: 2422 BARTELT RD APT 2A
Mailing City/State: IOWA CITY, IA 522462708
Convictions
Certified Abstract of Driving Record
DL/ID #: 261DD7091 (IA)
Class: D
Audit #: 5728984
Issue Date: 01/06/2012
Expiration Date: 01/16/2017
Endorsements: 3
Restrictions: NONE
Date of Birth: 1/16/1986
Sex: M
History Information
Customer #:
4640700
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
-Fail to Obey Traffic Sign/Signal
Citation Date
Conviction Date
ACD
Explanation
County
]UR
09/25/2010
'11/23/2010
892
Speed (10 mph &under In 35-55 mph zone)
152
Iowa Department of Transportation
04/21/2012
07/13/2012
M14
-Fail to Obey Traffic Sign/Signal
52
,IA
3A
Name: Hassan, Mohamad Awad DL/ID: 261DD7091
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
SA office, and that I have been authorized by the Director of the Iowa Department of Transportation to so certify.
to .••Itness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date:
'•?/,fpr
8/2/2012,ay}_
IOWA *4
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Office of Driver Services
Iowa Department of Transportation
Name: Hassan, Mohamad Awad DL/ID: 261DD7091