HomeMy WebLinkAbout12-182+ MIW®r�Il
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
(319) 356-5040 (t ALu E,S DA1c
(319) 356-5497 FAX (�
Authorization Number
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
(Office Use Only)
1. Name First ELTOUH Middle 8969M Last N,+ SAA v
2. Mailing Address a? 51'51 POba ,�1 d APF re;3. Telephone: Home 3 X17 653 a) 6o IfOther:
4. Prior experience in transportation of passengers: TA Z in Ne6W ✓62 <
C�
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /✓0
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? &I ()
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? /v 0
Type of offense /d! Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? ✓o
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)
derWtaAdmibadg 06/2012
6a3PP(7Z
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
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 C� r"" Date 6 ?:Z a J - I a
#**######**###########*##*##*#***********44*####*###########################*************************4###4####*############***#*#***************
STATE OF IOWA )
COUNTY OF JOHNSON )
ubscribed and sworn to before me by \itiss4On this a day of
Iblic in and fdr the State of Iowa 1,
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).
Poo hief or designee j p Date
City Clerk or designee Date
NOT VALID UNTIL Police Chief 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.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
deM=dnvMd9eepp2010.da 06/2012
Aug.21. 2012, 4:32PM1 Div �of Criminal Iitynvestigation
STATE OF IOWA
- Crimirkal lf3fiaforrTRecord Check --
Req>uegt .Fo>rm
To: Iowa Division of Crlmfnal hvestlgatton
SupportOpera4low Bureau, f'lzloor
215 Th 7°i Street
Das MoLtes,Iowa 60319
(515) 925-6066
(615),115-6080 Fax
No. 1231 P. 3/3
No. LI9U Y.
DCI AocountNumber; _ -qbna 17
(IrepplItablo)
From; CITY OF IOWA, CITY
CITY CUM'S OFFICE
410 r. WASMWGTON sTR)3n
IOWA CITY IOWA 52240
Phone: 319356-5041
Y'axl 319-356-5497
Iowa Criminal Mstory Record Check R-estllts
As of3 I1�`, a search of the provlded namo and date of bixin xevealed:
No Iowa CriminalHistolyRecord found iv&LDCI
El Iowa Cxit hW Ilistoxy Record attached, DCT
DCI initials
,P.raivad Timn Auv 79 9017 9-IAPM Mn 1090
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Iowa Department of Transportation
Office of Driver Services (Toll Free) 800-532-1121
PO Box 9204, Des Moines, IA 50306-9204 515-244-9124
FAX: 515-239-1237
Certified Abstract of Driving Record
Inquiry Date:
8/22/2012
DL/ID #:
623AH8178 (IA)
Name:
Hassan, Eltoum Hagar
Class:
D
Address:
2551 HOLIDAY RD APT FS
Audit #:
6238178
Restriction
None
Issue Date:
08/22/2012
City/State:
CORALVILLE, IA 522412787
Expiration Date:
01/01/2017
Endorsements;
3
Mailing Address:
2551 HOLIDAY RD APT F5
Restrictions:
NONE
Date of Birth:
1/1/1965
Mailing City/State:
CORALVILLE, IA 522412787
Sex:
M
History Information
CLEAR DRIVING RECORD
Name: Hassan, Eltoum Hagar DL/ID: 623AH8178
Customer #:
6009173
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
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:
•;GI �4
8/22/2012
IOWA Nv-°%
:;
`DRIVER.
Office of Driver Services
�X1Z117U---
Iowa Department of Transportation
Name: Hassan, Eltoum Hagar DL/ID: 623AH8178