HomeMy WebLinkAbout14-046 Authorization Number IQ - Z(o
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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 nt1P- 1� Midd�l�'} Last
1. Name /)C.41ia�?t2 /1-7z- G Z' /7 .455.4 /�'
2. Mailing Address fed ,i157/// (L Vs.?' S' 2 q
3. Telephone: Home Other:,,, Y) V// 2 l// - j�Lc
4. Prior experience in transportation of passengers: Yis
5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? tiV/0
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? ;
Type of Offense Where When
7. Have you been convicted of any traffic offenses in the last five years? ,U '7
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 1 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)
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)
elerkllaxidrivbadg 03/2013
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
336 ,Q/= 5`' . 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 fid' Date 2- 2 71-/5/
STATE OF IOWA
COUNTY OF JOHNSON )
ubscribed and sworn to before me by , -1 (-ossa ,n . On this day of
ry c " Ui4 .
Kota Public in anIfotate of Iowa -it3P`f
************************************************************************************************************************************************
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).
%r'i'
Signa re of P.•'c: 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.
717e-24,1-7t.---- A/ • .e2-4/1...)
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Signature of City Clerk or designee Date
Taxi cab businesses are required to provide Driver Identification cards. Cards must be 81/2" (width) and 5 '/2"
(height)and prominently displayed to all passengers.
Office Use Only
Approved application
DCI report
State certified driving record
Website update
ded axidrivbadgeapp2010.doc 03/2013
._
it Thfl State of Iowa Y<a5 r to
:0 of Puke,
Division of Criminal Investigation
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aQ 215E7 St <l �, 1°',.F
CA / IOWA i` Des Moines IA 50319 ^o�' „"°„..�. In
CA
5 Ph.515-725-6066 Fax 515-725-6050 F - `£J' `.
9off lioC' Iowa Criminal History Record Check kimiNi``t-1
Walk-In Request
Your name NaggME/) /lfj29N/ it- 7//lisA TO
Address Q4/ /1/2//74---g. ,WE fie/re AZ-
City/State/Zip SaW,A c-,r/ 7-A. S22 c'1 Fill in all shaded areas.
Phone#3/9- //32p- 2 Vi/
Requesting an Iowa criminal history record check on:
Last Name Apellido(mandatory) First Name Primer Nombre(mandatory) Middle Name Segundo Nombre(recommended)
il- ASA n) In#A,170 11/112AN i
Date of Birth Fecha Nacimiento(mandatory) Gender Genero(mandatory) SocialocSecurity Number(recommended)
12 -2 /7- S2 Male ['Female22 3-69- /3z
Waiver Signature Firma(If the request is on yourself,please sign. If the request is on someone else,write N/A.)
/7/%7AftV iii --.
Results 22�1 V\) DCI USE ONLY
As of —1 , a name and date of birth check revealed: ---
.)2No record found _
❑Record attached, DCI DCI# `•
DCI initials 9
0
Receipt
Number of requests 1 x $15.00 per last name=Total amount$ 1 5,0 °
Method of payment: %cash El money order Ocheck# ❑MasterCard or Visa
Cardholder's name Last 4 digits of MC or Visa
DCI initials gfi—
Credit Card Number# Exp. Date
0
0
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SMARTER I SIMPLER I CUSTOMER DRII+E'I iowadotgov
m Office of Driver Services
in PO Box 9204 Des Moines_IA 50306-9204
Phone_515 244-9124 1800-532-1121 I Fax:515-239-1837
WSYw:.iowadotgov
Certified Abstract of Driving Record
Inquiry Date: 2/25/2014 OLID 4: 335AE9503(IA) Customer 0: 5485005
Name: El Hassan,Mohamed Medan] Class: D ID Status~ EXP
Address: 961 MILLER AVE 51E 2 Audit A': 7773465 DL States: VAL
Immo Date: 02/07/2014 CDL Status: None
City/State: IOWA CITY,IA 522465316 Expiration Data: 01/06/2015 CDL Cat Status: None
Endorsements: 3 CDL Ned States: None
Mailing Address: 961 MILLER AVE STE 2 Restrictions: Corrective Lenses Restdctloe None
Date of DIM: 12/27/1962 - Supplement:
Marling aty/State: IOWA CIT',IA 522465316 Sex: M •
•
History Information
U
CLEAR DRIVING RECORD
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Name:El Hassan,Mnhamed Medanl DL/ID:336SE9503
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Pursuant to Iowa Code§321.50,L Kim Snook,Dlrerter of Cam of Driver Sepik ,Iowa Department of Transpartatlon,do heretry certify that I am the custodian of the records
held by the Office of Driver Services,that this Is a tae and accurate mpy elan of idal record currently In the custody of said office,and that I have been aut horned by the
o Dkeder of the Iowa Department of Transportation to so certify.
In witness whereof,l have caused my signature and the mal of the Department to be set upon Ms document,at Ankeny,Lova thb data:
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