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CITY OF IOWA CITY
410 East Washington Street
Iowa City, Iowa 52240-1826
-5040
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1. Name
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Authorization Number (9- 25
(Office Use Only)
AbpPN FOR TAXI
P ent review must be ma
en 8 a.m. to 3 p.m., Monday — Friday.
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2. Mailing Address 3 I Zc+a% ✓G C(archGt y4
3. Telephone: Home 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
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6. Have you been convicted of operating a motor vehicle while under the influence of alcohol or drugs in the last five
years? *I,!>
Type of Offense
Where
7. Have you been convicted of any traffic offenses in the last five years?
Type of offense
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WWhere-
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When
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8. Has your drivers license or chauffeur's license been suspended or revoked in the last five years? /)0
Type of offense
Where
When
9. Have you ever applied to bean 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)
clerb idrivbadg 09/2010
I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number
55 X (R `j�; YC: 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
Date Z-13- 1-Z
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STATE OF IOWA )
COUNTY OF JOHNSON )
Subscribed and sworn to before me by f3a.wo - iejz On this ( day of
t a o } SONDRAE FORT
! Commission Number 159781 S .�
My Commission Expim
3/7 /-? i Notary Public in and for the State of Iowa
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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).
ignatu of Police Chief or designee Date
Sig re of City Clerk or designee Date
After Police Chief and City Clerk have approved authorized taxi driver names will be placed on the city website at icgov.org.
Taxi cab businesses are required to provide Driver Identification cards.
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Office Use Only
Approved application
DCI report
State certified driving record
Website update
clerW idriv adBeapp2010 doc 09/2010
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Iowa Department of Transportation
Office of Driver Services (Coil Free) 800332-1124
PO Box 9204, Des Moines, IA 503N-9204 515-244-9124
4
FAX515-239-1837
1440
Inquiry Date: 1/27/2012
Name: Portz, Darwin Daniel
Address: 309 2ND AVE
City/State: CLARENCE, IA 522169756
Mailing Address: 309 2ND AVE
Mailing City/State: CLARENCE, IA 522169756
Convictions
Certified Abstract of Driving Record
DL/IO #: BBIRR9040 (IA)
Class: D
Audit #: 5765339
Issue Date: 01/27/2012
Expiration Date: 12/10/2013
Endorsements: 31-
Restrictions:
LRestrictions: NONE
Date of Birth: 12/10/1979
Sex: M
History Information
Customer #:
1613690
ID Status:
None
DL Status:
VAL
CDL Status:
None
CDL Cert Status:
None
CDL Med Status:
None
Restriction
None
Supplement:
Citation Date Conviction Date ACD _ Explanation _ _ _ County Jun
06/29/2011 �07/19/2011 S92 Speed (10 mph & under in 35-5S mph zone) dA
Name: Portz, Darwin Daniel DL/ID: 881RR9040
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: Portz, Darwin Daniel DL/ID: 8BIRR9040
1/27/2012
IOWA
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Office of Driver Services
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Iowa Department of Transportation
Name: Portz, Darwin Daniel DL/ID: 8BIRR9040
Feb. 7. 2012 1:37PM
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DCC
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Received Time Jan. 30. 2012 3:55PM No._7579