HomeMy WebLinkAbout13-186 Authorization Number / (?
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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.)
4,---towa-City, Iowa 52240-1826
L (319) 356-5040
(319) 356-5497 FAX
First Middle Last I
1. Name �L/0/1l� / AGAR 6:4-554/V
2. Mailing Address a s/O 90A-f2/f' ROI 4 ( Pi a D ; 1-e i,tia C/ k ,_774 5 •ny 6
3. Telephone: Home Other: '7y7 - 633 C)
4. Prior experience in transportation of passengers: I/C) ')24
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
4/0424
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years?
Type of Offense Where When
/t/c)
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?
Type of offense Where When
cJ ✓lZ
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).
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
clerk/taxidrivbadg 03/2013
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
a 49/4 )4 1 7 F . 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 itkt, Date 8 7 1 3
STATE OF IOWA
COUNTY OF JOHNSON )
Sub ribed and sworn _to before me by 7"�/ a SS . On this `2day of
a41 T
kirAd
t;�mber 2E1
8N tary Public in and for the State of Iowa
t • My u ,,‘ itec
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 ture of ':li • Chie 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.
/Ill.r7r2 /k . 11 i.- ;7
Sign ture of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8'/2" (width) and 51/2"
(height)and prominently displayed to all passengers.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
clerkftaxidrivbadgeapp2010.doc 03/2013
Aug. 16. 2013' 4:40PM�' Div of Criminal Investigation . ';: ; ', No. 4013.1 •• P. 7/8 ' •'
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OIowa Department of Transportation
I.. Office of Driver Services (Toll Free)800-632-1121
PO Box 9204,Des Moines,IA 50306-9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 8/13/2013 DL/ID It: 623AH8178 (IA) Customer 7t: 6009173
Name: Hassan, Eltoum Hagar Class: D ID Status: None
Address: 2551 HOLIDAY RD APT F5 Audit#: 6238178 DL Status: VAL
Issue Date: 08/22/2012 CDL Status: None
City/State: CORALVILLE, IA 522412787 Expiration Date: 01/01/2017 CDL Cert Status: None
Endorsements: 3 CDL Med Status: None
Mailing Address: 2551 HOLIDAY RD APT F5 Restrictions: NONE Restriction None
Date of 811th: 1/1/1965 Supplement:
Mailing City/State: CORALVILLE,IA 522412787 Sex: Ni
History Information
CLEAR DRIVING RECORD
Name: Hassan, Eltoum Hagar DL/ID: 623AH8178
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:
9';... C(Ep4`�4 8/13/2013
IOWA -.i E0
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e
D. O. T. a '
/'i4,,e,nAS Office
Services Department of Transportation
Name: Hassan, Eltoum Hagar DL/ID:623AH8178