HomeMy WebLinkAbout13-201 Authorization Number I S (c
a – 1 (Office Use Only)
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.)
wa City. Iowa 52240-1826
319) 356-504
(319) 3 - 497 FAX
First / Middle Last kv\ad
1. Name 4rvii G 1c rfle G�/1 q w1P j 1-4-0
2. Mailing Address 24'Lo Rcik- -- Z t =ic v•". ( I A S'2-21--f 6
3. Telephone: Home 717-433 U gat Other:
4. Prior experience ii)transportation of passengers:
111
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? _.� ..r•r'r.
Type of offense Where W -
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? /\...10
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? ,f
Type of offense Where When
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? N 0
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)
fU
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).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
derkltaxidnvbadg 03/2013
72y 4F 7'7
I� ereby certify that I have sued to me by the Iowa Department of Transportation a valid Chauffeur's license number
r• r'k h y -4-rqil".47CCA . 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 Applicant42,-i Date o421 J (3
STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by r4‘t.a6 HcW -ko4 1-V0 .c . On this --Si__A. day of
Notary Public in a for the State of I" a / ----
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).
x�if
�—� —� 3
,
Si ature Police Chief or designee 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.
71e.e.etyl--iC ?<-1------- 91" 1 _5SignatuCity Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width) and 5 1/2"
(height)and prominently displayed to all passengers.
................................................................................................................................................
Office Use Only
Approved application
DCI report
State certified driving record
Website update
clerWtaxidrivbadgeapp2010.doc 03/2013
Sep. 3. 2013, 3: 24PM Div of Criminal Investigation No, 5918 P. 4/9
aver. LI• cuIJ J,Jn , UI •) vuc. n VI t, VI ;Vila Vily Ito. Jouv f, L
. .y
lsikk
aؕ
eHtnhuillitigtoryRecord! Cheek c , y 44
;ircoaan • ;lna- •.\
ACIAoaoundN nzbert 400a l'-'‘
• - Gtep;ltoeelo) •
got hal bNls(osuOfCrSttig ilillastigAt(on From: can oh` TWA CM
!?uppoYCOperations Mtromu,1'tlrioor - QZXZ Watt's 0?AGE
2,5E 9'''MS(raat • 41n.w.c NAATriguro17'BTRSLT . I
beshloutas,rowa so319 ,
641ea 1u14601f • a
Vim 124-00o tag ,
Phone/ aro-MS-.501 •
l• iaxt 319—q5F--5497
IAmretu*st(n; farowA OrinITOTRiga . 'dvordCheokan; • ,
tatNote nendudo • J1XB@NArim(mdnda(ey ' Middle Nm6 (wmoeado) , '
htaw\ Y �M4Y Fk• % Ck •wp
C
Alto ogBfkih(manegory). 6f01((Xo,'CUnandataty) &WMgeoixtity]V1.ill1bor(( mama)? ..
‘ (7 2-A q 6S— ' V(/1a16. ' I1'Xj'emale f 6 6 26 7 73 7 .
1 aapei'Ionna(tur(;wii4outna($neawfly,,r omtTtesubjee1ofihoinw1aat;aeotnp(o(0ol txbtAlhtoforyreeordtnuynnc
ha yak nags,por Cade oO%ww,Chapter 69yz,Yol•sample(o arlni(nAThtstoryreeon/iaformntto 4n4allowod Gy(Avwt A(tmys
• ohfauhA realvera(fna(urettont MHo.subfootorttcaroalkst<
IThfevSa/rn serahtrobys(vaperm(vfoulerthoaeoYe>egmuInuoAivlafto(andvoloulowmthodnn1atraY[mnldeflo4oilthhfDM afCrimna(
iwosffgerronwell tio q/mhlelhatorydat4aenoctn(Ogma r,tlsmorntetnedQyth Choy botskawclaselomitylow,
Waiver54'gnature; . • , .
•
��NN = • ems`
- IOW CrIMThHll( tstorri/geord Check Results . rocfYraonyi
Aeo? �J1 �Asearoho thapYovidadnanaeaugTda?Q birthievealed: '
I ,
No Ydwg Cxlminifigistorylecord fmund wtthD C
•
I_,
El XonnnCrIuvnelXIiafoxyReCordattached,X)CX# —
Receiv ed Time Aug, 27, 2013 3:39PM No, 5321 iy '
ARTS Page 1 of 1
rill) Iowa Department of Transportation
J. Office of Driver Senrices (Toll Free)IMO-532-1121
414.1 PO Box 9204,Des Manes,IA 50308-9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 8/27/2013 DL/ID #: 424AF7780 (IA) Customer#: 5612537
Name: Hamad,Amar Hamad Class: D ID Status: None
Mohamed
Address: 2420 BARTELT RD APT Audit#: 5845747 DL Status: VAL
2D Issue Date: 03/09/2012 CDL Status: None
City/State: IOWA CITY, IA Expiration 11/22/2015 CDL Cert None
522462707 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 2420 BARTELT RD APT Restrictions: NONE Restriction None
2D Date of Birth: 11/22/1965 Supplement:
Mailing City/State: IOWA CIN, IA Sex: M
522462707
History Information
CLEAR DRIVING RECORD
Name: Hamad,Amar Hamad Mohamed DL/ID:424AF7780
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:
w Oqy
f_4... ****.". 8/27/2013
/4'1 IOWA t
tr
;fly
'y D. 0. T., ; tatiestk
a
\4f hA °et Office of Driver Services
Iowa Department of Transportation
Name: Hamad,Amar Hamad Mohamed DL/ID: 424AF7780
http://172.29.254.55/drivers/reports/customerhistory/certifteddrivingrecordaspx 8/27/2013