HomeMy WebLinkAbout13-175 Authorization Number 13 — J 75
- j _ 1 (Office Use Only)
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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.)
Iowa City. Iowa 52240-1826
(319) 356-5040
(319) 356-5497 FAX
First Middle Last
1. Name j)lc;hokyA AiAD 71/CLQ et,✓1
2. Mailing Address a4 a� ec r 1 1 te ) A j O -A- L 1- y . ?A a a4,6
3. Telephone: Home Other: -Sk t- 3a k - I bbe
4. Prior experience in transportation of passengers: _ `
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
Spee Corct\u;lIe ✓vo,r- 3 - ' o1/4O
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
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7. Have you been convicted of any traffic offenses in the last five years?
Type of offense Where When
r()%tt fo G,b&f f c e1 " 141- ►owl c,- 1-1 i„ttf.- '3 - a o ID
8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years?
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)
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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)
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derkfaxidrivbadg 03/2013
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license numb.r
`),6 ` 'l7 P ('t\ . 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 r^'� % Date A-(. _ /Z - \
STATE OF IOWA )
COUNTY OF JOHNSON )
Subs ribed and sworn to before me by / 7 7c. `1 at e}" -// Cc SS cz ��--On this /6'��- day of
z6c
KELLIE K.TUTTLE l�
J' ccinr Num x221819 Notary Public in and for the State of Iowa
co •m; rr
My co r�is io x ares
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).
= '. ,0/3
Signre liej re of 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.
-/l - ,2,7/
Signatu of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 '/z" (width) and 51/2"
(height) and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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Uerkftaxidrivbadgeapp2010.doc 03/2013
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Iowa Department of Transportation
#r Office of Dmfef Services (Toil Free)800-532-1121
PO Box 9204,Des Moines,IA 50300-9204 515-244-9124
FAX:515-239-1837
Certified Abstract of Driving Record
Inquiry Date: 8/15/2013 DL/ID#: 261DD7091 (IA) Customer#: 4640700
Name: Hassan, Mohamad Awad Class: D ED Status: None
Address: 2422 BARTELT RD APT Audit#: 5728984 DL Status: VAL
2A Issue Date: 01/06/2012 CDL Status: None
City/State: IOWA CITY,IA Expiration 01/16/2017 CDL Cert None
522462708 Date: Status:
Endorsements: 3 CDL Med None
Status:
Mailing Address: 2422 BARTELT RD APT Restrictions: NONE Restriction None
2A Date of Birth: 1/16/1986 Supplement:
Mailing City/State: IOWA CITY,IA Sex: M
522462708
History Information
Convictions
Citation Date Conviction Date ACD Explanation County JUR
09/25/2010 '11/23/2010 __ _, S92 `Speed (10 mph&under in 35-55 mph zone) ;Johnson IA
04/21/2012 07/13/2012 M14 ;Fail to Obey Traffic Sign/Signal jlohnson IA
06/11/2013 07/10/2013 593 Speed IL
Name: Hassan, Mohamad Awad DL/ID: 261DD7091
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;
.Zt.... *"et V 8/15/2013
( c : 4)
•1'c4OaSOffIowiceofa Driver
Services
ansportation
Name: Hassan, Mohamad Awad DL/ID: 261DD7091
Aug. 15. 2013" 3: 21PMDiv of Criminal Investigation. ,No. 2728, •,.P 2 •
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Received Time Aug. 1. 2013 11 :49AMaa6.,2249 '2-- . '