HomeMy WebLinkAbout12-285I r ,
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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
zll l
(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)
First IE1S5A 5
Middle Last 1 I A 5spw\
1. Name C�
2. Mailing Address RM I kg—n kp K s+ A4:) / *I -7 , 10(- A Cid-V, I r4 6-92LL40
3. Telephone: Home 0 f9 — ?3 3 _,-� — �, S 1' 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? N0
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? ----NO
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? No
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? No
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) �Q
DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATE EIxTiFIED
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)
derMmidriv dg 09/2012
& S -14H 301 e
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
El.554 j-H/155A-V . 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
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by `sasr<, On this /9, day of
'j,r +II SONDRAE FORT
Io
CoMY�ommmission 1588891
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).
ig_ a of Police Chief or designee
/2 /1 -12-
Date
YOU ARE NOT VALID TO DRIVE A TAXI IN IOWA CITY UNTIL AUTHORIZATION IS RECEIVED FROM THE CITY
CLERK'S OFFICE. Authorized taxi driver names are placed on the city website at icgov.org.
/
7e
Signatbfe of City Clerk or designee
Taxi cab businesses are required to provide Driver Identification cards.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
/g, — loges
Date
der faxidrlvbadgeapp201 o.doc 09/2012
t
Page 1 of 1
Iowa Department of Transportation
Office of Driver Services (Toll Free) ON -532-1121
PO Box.92E4, Des MoinM [A 503M204 515-244-9124
FAX 515-2391837
Certified Abstract of Driving Record
Inquiry Date:
12/14/2012 DL/ID #:
651AH3018 (IA)
Customer #:
6038623
Name:
Hassan, Eissa Sidahmed Class:
D
ID Status:
None
Address:
2001 KEOKUK ST APT 7 Audit #:
6513018
DL Status:
VAL
Issue Date:
12/04/2012
CDL Status:
None .
City/State:
IOWA CIN, IA Expiration
08/01/2017
CDL Cert
None
522404430 Date:
Status:
Endorsements: 3
CDL Med
None
Status:
Mailing Address:
2001 KEOKUK ST APT 7 Restrictions:
NONE
Restriction
None
Date of Birth:
8/1/1971
Supplement:
Mailing City/State: IOWA CIN, IA Sex:
M
r
522404430
History Information
CLEAR DRIVING RECORD
Name: Hassan, Eissa Sidahmed DL/ID: 651AH3018
Pursuant to Iowa Code §321.10, I, Kim Snook,. Director of Ojfice, 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:
Name: Hassan, Eissa Sidahmed DL/ID: 651AH3018
12/14/2012
4
Office of Driver Services
Iowa Department of Transportation
12/14/2012
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Received Time Dec. 4. 2012 10:08AM No -7400
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