HomeMy WebLinkAbout13-026Authorization Number 13 - "
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APPLICATION FOR TAXI DRIVER
CITY OF IOWA CITY (Police Department review must be made
41 0 East Washington Street between 8 a.m. to 3 p.m., Monday - Friday.)
Iowa Cit . Iowa 52240-I 26
�3 356- �i X79
(319) 356-5497 FAX
Last l ^ 1
1. Name First Middle ��i-1 vv1 Alntn't-ed �4SS�^'I
2. Mailing Address `?'A tZ1F 1 B fowri GVy T 0 S2Z M�
3. Telephone: Home 319 4Oo - 9 2L 3 Other:
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
6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? rJg
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? 'J e
Tvoe of offense Where When
secj C A \k Is- 2bacl
8. Has your drivel's license or chauffeurs license been suspended or revoked in the last five years? N b
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) The re-
port will be mailed to the individual making the request and needs to be reviewed by the Police Chief with this appli-
cation.
(OVER FOR REQUIRED SIGNATURE AND NOTARY)
U¢i .dd�dg 09/2012
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
C o a G (, 5, 3 . 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
STATE OF IOWA )
COUNTY OF JOHNSON ) I I 1
scribedud worn to before me by {{Q l nl � ��CLII^?�� On this l day of
i�
Public in and for the State of Iowa
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).
a/.�/,�
Sign ture of olice ief or esignee 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.
�ke2"'9� - 9 ��
Signalum of City Clerk or designee
Taxi cab businesses are required to provide Driver Identification cards.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
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d�idnwadqeapp2010 d 09/2012
Feb. 11. 2013 1:10PM
heb. 1. 2013 2:231'M
Div of Criminal Investigation
City Clerk — City o1 Iowa City
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L 1 `9010- 9. 99DAE-AI_ 1-190
Iowa Department of Transportation
Office of Driver Services (Toll Free) 800-532-1121
PO Box 9204, Des Moines, !A 543136-92Q4 515-249-9124
1440 FAX: 515-239-1837
Certified Abstract of Driving Record
Inquiry Date:
2/1/2013
DL/ID #: 570AG6289 (IA)
Customer #:
5911203
Name:
Mohamed, Hatim
Class: A
ID Status:
None
Ahmed Husseen
Address:
2402 BARTELT RD APT
Audit #: 5988411
DL Status:
VAL
IB
Issue Date: 05/17/2012
CDL Status:
VAL
City/State:
IOWA CITY, IA
Expiration 01/01/2016
CDL Cert
None
522462703
Date:
Status:
Endorsements: NONE
CDL Med
None
Status:
Mailing Address:
2402 BARTELT RD APT
Restrictions: NONE
Restriction
None
1B
Date of Birth: 1/1/1973
Supplement:
Mailing City/State: IOWA CITY, IA
Sex: M
522462703
History Information
Convictions
Citation Date
Conviction Date
ACD Explanation
County 3UR
11/15/2009_
'03/12/2010
S94 Speed
:. 'CA
05/11/201205/17/2012
_ _
F04 Seat Belt Violation
52 IA
Name: Mohamed, Hatim Ahmed Husseen DL/ID: S70AG6289
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:
Name: Mohamed, Hatim Ahmed Husseen DL/ID: 570AG6289
2/1/2013
IOWA Nq
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Office of Driver Services
Iowa Department of Transportation
Name: Mohamed, Hatim Ahmed Husseen DL/ID: 570AG6289