HomeMy WebLinkAbout12-209it"III
CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
319) 356-50 ( �4✓s,�. ,
(3 19) 356-5497 FAX 7
1. Name
2. Mailing
3. Telephone: Home -3I12DZ 6� I
Authorization Number / Q� ";1109
(Office Use Only)
APPLICATION FOR TAXI DRIVER
(Police Department review must be made
between 8 a.m. to 3 p.m., Monday — Friday.)
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? NO
Type of offense Where When
6. Have you beep convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? /1/Q
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? .6/n
Type of offense Where When
S. Has your drivel's license or chauffeur's license been suspended or revoked in the last five years? C)
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)
de !t idrlvbadg 09/2010
I hereby certifythat I 1 ave issued to me by the Iowa Department of Transportation a valid Chauffeurs license'humber
_�I
7 ' A L2 /14� iEr I understand that if I falsely answer any questions in this application, that tNs
application may be erred. 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 6e signed in front
of a Notary Public)
CS
Signature of Applicant / — Date o9/J3fz-1Z
N++++*++++++NNNfN+fNf+++NNN+++f+N+N#NNN++++NN+++++N++#+++++fNN+ffN+NY*f#f*N*#t++N*+Nf1f#f f+1+f f f++f 1NNN#NNNf1*+fN
STATE OF IOWA )
COUNTY OF JOHNSON )
S scribed and sworn to before me by
L �oj 2
KELLIE K. TUTTLE
On this I --�' "day of
kL(-e lL/'u (F r i
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).
Sig ure o ce C ief or designee
kll
Signatilre of City Clerk or designee
Date
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.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
d�baaV�MOi 09/2010
mugs.24. tvIz 9:OoPM DrjVj k, iiyouie�x - ui[ynorsiovatLoty No.2/383 F. !1
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STATE OF IOWA
— Criminal-Ri9toiryRecord Check
Request ]corm
To; Iowa Division of Criminal bivestigatlon
Support overailowBilreau, 13'Plool,
215117'I' Street
bes Moines, Iowo 50319
(515) 725-6066
(515)725.6080 Falt
I am regaastina an Iowa (,rlminal Mstory Record Check on:
MI A.ccountNmnhor; "&n �7-- r
(st> PHMbie)
From: CITY OF IOWA CITY
CITY CLZRX'S OM4 CL
41D Lr. WA8ff NGT0N 8TR3?U
IOWA CITY IOWA 52240
Phone; 319-396-9041
I?ax: 319356-5497
Last NRMO mandafory
'r9t NamOP(fflandafdr3r)Middle
Nnxue (rewmmvaco
It d
/2�
/' hO h 4Date
of Birth (niondmo[y)
Gender mmAndSocial
Seeurl NUMber recommended
j d �J
Waiver, lnforination: Wlthoutasignedwaiverfromthesubjeatofiliarequest,acompletecriminalhistoryrecordmaynet
berelensable, pat• Code of Iowo, Chapter 692.2. For co to criminal history record information, as allowed bylaw, always
ebtain a waiver ei2natare from the sublect of ilia reauest
Waivev Relertse; l hueby give Panlsston for ilio abovo requcsiing officipl m conduct as IoWac iminal hlsforyrecord cherkwldi the DlYlslon olCYlminel
Invesiteallon (DCD..Any crlmhial hisfory dela concamingme Ihu fo nfainte[ne4 by the DCtnlay be refessed as ollowed 6y fmv.
Waiver
Iowa Criminal_ History Record eck.Result i clos i,,>
cn Tl
As of g a searoh of tho provided name and date of bixth revealed: c-, "' o
--a 03
Z �a
No Iowa Criminal History Recoxd found with D CT ti! y
r— CO
Iowa Criminal Mstoxy Record attached, DCT#
DCT
j e c e i v e d T1ifine,Au�rYl.7,,t2012 3:46PM No. 162
CA
Iowa Department of Transportation
Office of Driver Services (foNFree) 800-532-1121
PO Box 9204, Des Moines, fA 503DM204 515-244-9124
FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
8/15/2012
DL/ID #:
243AD4645 (IA)
Customer #:
5400638
Name:
Hamad, Mogahed
Class:
D
ID Status:
None
Improper Registration
Mohamed Alhassa
'IA
Address:
2654 ROBERTS RD APT
Audit #:
6192585
DL Status:
VAL
2B
Issue Date:
08/07/2012
CDL Status:
None
City/State:
IOWA CITY, IA
Expiration
08/02/2013
LDL Cert
None
522462741
Date:
Status:
Endorsements:
3
CDL Med
None
Status:
Mailing Address:
2654 ROBERTS RD APT
Restrictions:
NONE
Restriction
None
2B
Date of Birth:
8/2/1980
Supplement:
Mailing City/State: IOWA CITY, IA
Sex:
M
522462741
History Information
Convictions
Citation Date
Conviction Date
ACD Explanation
County
]UR
02/03/2009
02/23/2009
Speed (10 mph & under in 35-55 mph zone)
57
IA
10/21/2011
12/04/2011
Improper Registration
57
'IA
Name: Hamad, Mogahed Mohamed Alhassa DL/ID: 243AD4645
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:
;,7"'•"•Y;`/,pay
8/15/2012
IOWA r;
D. 0.
7p '•••"' $=
Office of Driver Services
Iowa Department of Transportation
Name: Hamad, Mogahed Mohamed Alhassa DL/ID: 243AD4645