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HomeMy WebLinkAbout13-127 Authorization Number 13 /2'7 1 (Office Use Only) _02 illlI 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 A/a s P >-- B, \ A j S e-c✓i 2. Mailing Address j� l ,/- I } Vak t A lc.„tea 7 2. 3. Telephone: Home- 3 Kr 6.-/(/ Other: 4. Prior experience in transportation of passengers: 1`'✓ S 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? /vO 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? Ai Type of Offense Where When 7. Have you been convicted of any traffic offenses in the last five years? A)() 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/7,' 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) /(0 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) clerknaxidrivbadg 03/2013 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license numberk 3s-1 Ar 60-Al . 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 0.61 D STATE OF IOWA COUNTY OF JOHNSON ) Subscribed and sworn to before me by /V c.Ss r vAtctSS ` . On this 7 day of 1c-vvavi3 __ o'gym SONDRAE FORT `s 1' _ • Commission Number 159791 My Commission Expires Notary Public in and for the State of Iowa 3/7 /1.-ZG'/ ,5" 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). ignatuof Police Chief or designee o 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. 2;7 4 ii,e/ - 7- is Signa re of City 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 clerkAaxidrivbadgeapp2010.doc 03/2013 ' Jinn. 5. 2013 12:48PM Div of Criminal Investigation K . 5875' P. 6/8 - .• oull. i• LV I-1I1 L•L71In •,.I ty vicin . bI tp in J1./(rd UI Ly • I •KU. .17 IU F. L ,' J . I 1 • . f I • • 1 I • • - I .- , • • • . J_ r i 1 l • fel 71 1•Vr /.Ill ' I 1 . I 4•.r I. i tt % eco. � �tvVn'la {.rna'Y , Sal St l ' SPAl.�X ®. a i[®WLA y,,, -;7 • . ,1i y LovLmx SII Cri�adrag$.arlst'o7'y�.Record Cheeks ! C fli y fr; c ' - 1,,,.. -. lEo®f Gte��1F'omssa I .0)-.147:4;„4,- 0 , 1-.1J„rki.%'' "'P I . 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NolhwmCrluinaLB)oto\ykeg cal Au-adwith DOI • — I • -E •town Griminal.!lstfory?mord attaahed,JDCXe -- Received Time Jun. 3. 2013 19: 29PM °, X526 ARTS Page 1 of 1 LAi 14171 Iowa Department of Transportation . Office of Driver Services Jai Free) -532-1121 PO Box 9204,Des Moines,IA 5031)6-9204 515-244-9124 FAX:515-239-1837 Certified Abstract of Driving Record Inquiry Date: 6/7/2013 DL/ID#: 359AE6149 (IA) Customer#: 5535082 Name: Hassan, Nasser Barakat Class: D ID Status: None Address: 2530 BARTELT RD APT Audit#: 4522364 DL Status: VAL 1A Issue Date: 07/17/2010 CDL Status: None City/State: IOWA CITY, IA Expiration 01/10/2014 CDL Cert None 522462719 Date: Status: Endorsements: 3 CDL Med None Status: Mailing Address: 2530 BARTELT RD APT Restrictions: NONE Restriction None 1A Date of Birth: 1/10/1975 Supplement: Mailing City/State: IOWA CITY, IA Sex: M 522462719 History Information Convictions Citation Date Conviction Date ACD Explanation County JUR 10/31/2009 12/17/2009 'S92 'Speed 152 IA 02/12/2011 03/28/2011 M14 .Fail to Obey Traffic Sign/Signal 52 IA i 10/18/2011 01/11/2012 ;593 Speed 52 IA 10/22/2011 01/11/2012 :M14 ;Fall to Obey Traffic Sign/Signal 52 IA Name: Hassan, Nasser Barakat DL/ID: 359AE6149 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: siliarml ta.•... ..•/`Iy i 6/7/2013 Ili IOWA 4 o y:c D. O. T.Pe c , ... , ^' s ,88115,--4- OffIowaleof Driver Department ofTransportation Name: Hassan, Nasser Barakat DL/ID: 359AE6149 http://172.29.254.55/drivers/reports/customerhistory/certifieddrivingrecord.aspx 6/7/2013