HomeMy WebLinkAbout12-168r Authorization Number /;— 1(.9
(Office Use Only)
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APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
410 East Washington Street between 8 a.m. to 3 p.m., Monday— Friday.)
Iowa City. Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
First Middle Last
1. Name�/� cyc G' �+ t L') v,ru,fl
2. Mailing Address �, �O y -A (:A
3. Telephone: Home Other:
4. Prior experience in transportation of passengers:
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /V'o
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?A ZO_
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? A ' �
TVDe 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)
clerMaxidrivbadg 06/2012
hereby certfy that I h1ave1 issued to me by the Iowa Department of Transportation a valid Chauffeurs license numbed
SS aZlTT ti0.CSC' Y) 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 c*De ) (T 1 112
ii#H#*##*##*#R#*R***HRf RHiffHY#Hi##+Y#+i##i+#H#HRH*RH*RRRf##R*f **RRRHRIffHHHfffHfHfHfYYf ffHYfi####H##+HH#RHfRff*+Hff f tfRH
STATE OF IOWA )
COUNTY OF JOHNSON
bscribed and sworrrl to before me by �QS�a' r ��Q "�� On this �% day of
21J l�—
P.C-f—f P _ �a [�� ro
Kr WE K. TUTTLE Notary Public in and for the State of Iowa
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).
Signature of Wice Ghief or designee Date
Si re of City Clerk or designee Date
NOT VALID UNTIL Police and 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.
*****R1HHH1fH11HHH##}}#}*iHHH11f11f f #!H#1ffH#H**}***}*##4**4H1f HR*f #RH1111f f111HH11HHf#N###4H#+}ftt#*tt*f**tH11M#f#######
Office Use Only
Approved application
DCI report
State certified driving record
Website update
de midnvbadgeapp2010 dm 06/2012
Iowa Department
Office of Driver Services
PO Box 9204, Des Moines, IA 503015-9204
Inquiry Date: 8/17/2012
Name: Hassan, Nasser Barakat
Address: 2530 BARTELT RD APT 1A
City/State: IOWA CITY, IA 522462719
Mailing Address: 2530 BARTELT RD APT IA
Mailing City/State: IOWA CITY, IA 522462719
Convictions
of Transportation
(Toll Free) 800-532-1121
515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
DL/ID #: 359AE6149 (IA)
Class: D
Audit #: 4522364
Issue Date: 07/17/2010
Expiration Date: 01/10/2014
Endorsements: 3
Restrictions: NONE
Date of Birth: 1/10/1975
Sex: M
History Information
Customer #:
5535082
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
3UR
10/31/2009
12/17/2009 _
_
S92
.Speed
52
IA
02/12/2011
_ _
03/28/2011_
_
M14
Fail to Obey Traffic Sign/Signal
52
IA
10%18/2011
.01/11/_2012_
593
_
Speed
52
IA
10/22/2011
_
X01/11/2012
M14
Fall to Obey Traffic Sign/Signal
_
52
_
TA
Name: Hassan, Nasser Barakat DL/ID: 359AE6149
Pursuant to Iowa Code §321.10, 1, 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:
°""'•f;T/V��
•'
8/17/2012
10 : *°
.
......
Office Office of Driver Services
a..R—'
Iowa Department of Transportation
Name: Hassan, Nasser Barakat DL/ID: 359AE6149
Aug,11. 2012 9:56AM Div of -Criminal Investigation No.9444 P 2
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Received Time Aug. 13. 2012 1:31PM No, 1231
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