HomeMy WebLinkAbout13-107 Authorization Number \3 -\Orl
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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 Wt S k�
2. Mailing Address 1 6)0 3 G- ��kti�C w.c,A , i7 t- S > ` ��'\ , 1 6 S ZZ` o
3. Telephone: Home X. I `1 _ 3 _ 2 U 2 It Other: - 6 31 — Li ci 2
4. Prior experience in transportation of passengers: 4R t.0 Y '
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere?
Type of offense Where When
( l -1
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
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense Where When
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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)
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)
derk/taxidrivbadg 03/2013
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I herebycertify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
71, S
\j '' 2. 7.___ . 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 wit _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 i ' Date 5 --1 0 - i 3
STATE OF IOWA )
COUNTY OF JOHNSON )
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Subscribed and sworn to before me by .-; n`�- , .� . v, -C2c . •n this 1, 3' day of
C \c,.._\\\.1o^ 9
Notary Public in and for the State of Iowa -7 ( (H
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).
,/Ay%l ,5—:–/q-1.-?Sig ture of 'fill,e Ch le 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.
Signature of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 8 1/2" (width)and 51/2"
(height) and prominently displayed to all passengers.
************************************************************************************************************************************************
Office Use Only
Approved application
DCI report
State certified driving record
Website update
c erkltaxidrivbadgeapp2o10.doc 03/2013
F Fib. 26. 2013 9:40AM Div of Criminal Investigation No. 4528 P. 2
•) Feb. 19. 2013 10:43AM City Clerk - City of Iowa City No. 3235 P. 2
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Del initials 1
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4111) IowaDepartment of Transportation
flir Office of Driver Services #Toll Free)800-532-1121
PO Box 9204,Des MoInes,IA 50306-9204 515-244-9124
FAX:516-23g-1837
Certified Abstract of Driving Record
Inquiry Date: 2/19/2013 DL/ID#: 713YY5282 (IA) Customer#: 435513
Name: Moustafa, Hatem Class: B ID Status: None
Mohamed
Address: 1803 GRANTWOOD DR Audit#: 5104078 DL Status: VAL
Issue Date: 03/23/2011 CDL Status: VAL
City/State: IOWA CITY,IA Expiration 04/23/2016 CDL Cert None
522405959 Date: Status:
Endorsements: P CDL Med None
Status:
Mailing Address: 1803 GRANTWOOD DR Restrictions: Corrective Lenses, Restriction None
Vehicle without air Supplement:
brakes
Date of Birth: 4/23/1965 •
Mailing City/State: IOWA CITY, IA Sex: M
522405959
History Information
CLEAR DRIVING RECORD
Name: Moustafa, Hatem Mohamed DL/ID: 713YY5282
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:
'dEN.61°4a
ctc. ....404, 2/19/2013
IOWA Vat0 a coLocrea
,'1j�'�� rvices
�A $�` Iowa Department Office of Driver eof Transportation
Name: Moustafa, Hatem Mohamed DL/ID: 713YY5282