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Home My WebLink About12-034I +` SWM®�� CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319) 356-5497 FAX 1. Name —, Authorization Number ( Z— 3cf (Office Use Only) APPLICATION FOR TAXI DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday.) Last 2. Mailing Address 14r9 /g ^j 3. Telephone: Home 31 9 930 -jY Other: F 4. Prior experience in transportation of passengers: % �.� �G-X, r2,¢,ee 5. Have you ever been convicted of any misdemeanors and/or felonies in this State or elsewhere? 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? /7 Type of Offense Where When Cr -,e te5S 7. Have you been convicted of any traffic offenses in the last five years?(fie 5 Type of offense Where When r�wa 8. Has your drivers 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) 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) dens idnmada 09/2010 I hereby certify that 1 have issued to me by the Iowa Department of Transportation a valid Chauffeurs license number b Ar X X 5 7 b 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 - / 2 a STATE OF IOWA ) COUNTY OF JOHNSON ) �� Subscribed and wom to before me by On this 4 day of \t,(`otary Nblic in and for the State of Iowa �131'`� RRM**MM*R**iR*M*M**M**MfM*1f11RR11M111f11Nf}1ff1111fN11fl1f1fRMRMRllR1fRRRMlMf*M*M!R**R****#}*R**MRk#####}111}N11}f1Rlfflf11f111fffHffiflflf 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). Sign lure o4Police i ordesi , ee Signature of City Clerk or designee tea iy �c�z Data a-111-1 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. ff11f1YYR11fY%fYYYYYYY%t%%Y#Y%#%fYfllHfi1111%%%11111%11111f11N%flf4tli%llffiff%N%ft Office Use Only Approved application DCI report State certified driving record Website update deM1 =idnvbadgeapp2041do 09/2010 \ Feb. 8. 2012 11:11AM Div of Criminal In . - -•Lvj�- a✓Ayjibal.JEllisto>ry Record Check r Iiegtxest Forun To. XosvaTltofslOnefGlfmrhal7nvavtt�gt(Oh Support operalfony )3Urenu,14, RIO or 2X3 E, 714Streoi bo9MgFgesrlot4n 50319 (515) 72s.066 (515)125-6090 k'ax lV 1-z. W11hou t a bo i'olepsnble, per Code )DtiI ACCouatNumbor: "'f OC4— P . QfePPlMMO) i r. •ill\ �\ ,qi. Aitone: 319-956-.5041 19X: 319-356-5407 aga'le ' O emale I Wa Ver feoln tbesubject 6922.2, b'or coMblole-cl•;ml Mlddlo Ala Social Seat Lli-�3 0'7t 70``17 W, q complete clfminpl history record cony not record Information, as alinwod by Iq%v, Il(wnys WrziveN.l2e1's�tse: Ilurebygfre pefminlon tDr IAo above requcsling olfiolpl to ronducl an Iowa oflminPl (ilslory(ecoid checkwilh Iha D�lalon orC„minal Ynvostlgelmq (pCq, Any ortmMelAfsrory dalq ouneem(ngmolAatismafnlalniQb.V:he DGlmeyboreleasdIm ollowed byfavv. UWA %.IAillAAlt1AJQ.O, t)1CY.MrVOZt1 a,,nOC.K KeSU1CS MClaroonln As of a search Of the provided name and data ofbuthx0yealed;rVj . No ioWa Cdwined Histozy keaord found Wlth b CT LI Iowa CTimfnal Histox.Record attoolled, 1) 0-1 I)CT DW -77 (09/25/10) Received Time Feb. 1. 2012 3:28PM No. µ YR.,91:�•�t .1 )DtiI ACCouatNumbor: "'f OC4— P . QfePPlMMO) i r. •ill\ �\ ,qi. Aitone: 319-956-.5041 19X: 319-356-5407 aga'le ' O emale I Wa Ver feoln tbesubject 6922.2, b'or coMblole-cl•;ml Mlddlo Ala Social Seat Lli-�3 0'7t 70``17 W, q complete clfminpl history record cony not record Information, as alinwod by Iq%v, Il(wnys WrziveN.l2e1's�tse: Ilurebygfre pefminlon tDr IAo above requcsling olfiolpl to ronducl an Iowa oflminPl (ilslory(ecoid checkwilh Iha D�lalon orC„minal Ynvostlgelmq (pCq, Any ortmMelAfsrory dalq ouneem(ngmolAatismafnlalniQb.V:he DGlmeyboreleasdIm ollowed byfavv. UWA %.IAillAAlt1AJQ.O, t)1CY.MrVOZt1 a,,nOC.K KeSU1CS MClaroonln As of a search Of the provided name and data ofbuthx0yealed;rVj . No ioWa Cdwined Histozy keaord found Wlth b CT LI Iowa CTimfnal Histox.Record attoolled, 1) 0-1 I)CT DW -77 (09/25/10) Received Time Feb. 1. 2012 3:28PM No. L Office of Driver Servicestl W13-532-11211 'O :a. 9204, Des Modnes, 515-244-9124 r -1837 Inquiry Date: 2/14/2012 Name: Wirtz, Adam Wesley Address: 911 HIGHLAND AVE City/State: IOWA CIN, IA 522402151 Mailing Address: 911 HIGHLAND AVE Mailing City/State: IOWA CITY, IA 522402151 Convictions Certified Abstract of Driving Record OL/ID #: 687XX5403 (IA) Customer #: 4106462 Class: D ID Status: VAL Audit #: 4863256 DL Status: VAL Issue Date: 12/04/2010 CDL Status: None Expiration Date: 10/19/2015 CDL Cert Status: None Endorsements: 3 CDL Med Status: None Restrictions: NONE Restriction None Date of Birth: 10/19/1982 Supplement: m0 ._ ___. _..�..... ;10/12/2011 Sex: M _. _ ..^ -:IA 12/10/2007 09/09/2009 History Information Citation Date Conviction Date ACD Explanation County 7uR 07/22/200i 04/20/2007 1351 No Driver's License ,52 !IA = _'- _.. _.. 11/03/2006 -..._....... ..._ ...... €04/20/2007 ..._._ ..._._...____ _M ._ _. ..._. _... ._.._ ._ ;1351 No Driver's License _ 152 SIA '< 7' !03/08/2007 1351 cNo Driver's License `57 IA 06/15/2007 _ 09/2007620 'Driving While Suspended DeniedCancelled Revoked -.._.._ �...�,,.�._ 52 SIA _Hl 06/15/2007 08/10/2007 ; Ice No Insurance Card 52 IA .. ......_._._. _... 09/17/2011 m0 ._ ___. _..�..... ;10/12/2011 ..__a... _...__ _.. _...w_.. ......._.. _... __....._..__............�....._....._............_._. M81 .Careless Driving _..... _e._.-. 52 _. _ ..^ -:IA Sanctions Type Effective End ACD Explanation Occurrence JAR 414 Suspended '06/13/2007 (09/10/2007 IWO1 ;Habitual Violator P. IOWA Ia lo, IA SIA i Suspended 09/10/2007 109/09/2009 D53 .Non Pa mentofIowa Fine IA ;IA = Suspended 09/11/2007 €12/08/2007 �B26 iDrlving While Suspended Denied, Cancelled Revoked IA Suspended _10/23/2007 X06/25/2008D53 Non -Payment of Iowa Fine_ _ IA ,IA Suspended 10/24/2007 ,09/09/2009 aD53 ;Non -Payment of Iowa Fine IA !IA '- Suspended 12/10/2007 09/09/2009 •D53 Non Payment of Iowa _ Fine .m _ _. -IA IA Suspended 12/10/2007 109/09/2009 D53 Non -Payment of Iowa Fine 7A Suspended .03/13/2008 109/09/2009 D53 =Non Payment of Iowa Fine IA IA Suspended 03/13/2008 `09/09/2009 D53 ,Non Payment of Iowa Fine IA Suspended -03/27/2008 109/09/2009 :D53 ;Non -Payment of Iowa Fine IA ,IA Name: Wirtz, Adam Wesley DL/ID: 687XX5403 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: vieici� oi''€�� • ��S'4� 2/14/2012 P. IOWA Ia lo, /l'i ,Opt pgljjEf,s Office of Driver Services Iowa Department of Transportation + Name: Wirtz, Adam Wesley DL/ID: 687XX5403