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Home My WebLink About16-069VIII CITY OF IOWA CITY 410 East Washington Street Iona City, Iowa 52240- 1826 (3 19) 356-5040 (3 19) 356-5497 FAX 1. Name (REQUIRED) . IDENTIFICATION NO. (Office Use Only) APPLICATION FOR TAXICAB / MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday — Friday) Failure to complete the "required" information will result in denial of the application Middle 2. Address (REQUIRED) 5(:-,/ IV /),Lvoe sr G,„g %rr$ 1, $27SS 3 Contact Information (REQUIRED) Email: 57,, e f �,: I. cam.. Cell Phone: 3/l/ - 1'3v - 995 r (All written communication sent via email) 4a. Chauffeur's License expiration date (REQUIRED) 2C,17 b. Taxicab Business Name (REQUIRED) Kt //ou/ C,.,, a -'r -7, C. { � 5, Prior experience in transportation of passengers: '41 L.Is 05 CYC c/r l e, 6, Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? Type of offense Where When 54,jxcjv/e -�L PO5(3 S' , 5 ca g0rS �_!r•frl,moi./ v7 r ��oi h 1 6 5 Cr 7 /f Z rz What happened to the charge? (Circle one) Convicted Dismissed Deferred Suspended Plead Guilty Other Have you been arrested / charged with any traffic offenses in the last five years? Where When What happened to the charge? (Circle one) Convicted Dismissed Deferred SuspendedPlead Guil Other 8. Has your driver's license or chauffeur's license been suspended or revoked in the last five years? /70 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 DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATEmCE14TI41) n DRIVING RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE dHi REVIEW ft a You must apply for an individual Department of Criminal Investigation Report (form available upa. request). (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) t J 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 I hereby certify that I have issued to me by the Iowa Department of Transportation a valid Chauffeur's license number 35°! IS 2073 issued on !a-/S-2vr/expiring on 41-21J- 7 01 7 . I understand that if I falsely answer any questions in this application, that this application may 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 authorization to be a taxicab driver 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 Applicantz,,_r_ r Date 3 - 3_�-- / 6 STATE OF IOWA ) COUNTYOFJOHNSON ) Subscribed and sworn to before me by Crlt"e9'oti on this _�o day of M'�L)A 1=0 tP . I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that there is no information which would indicate that the issuance would be detrimental to the safety, health or welfare of resi- dents of the City of Iowa City (Title 5, Chapter 2, City Code). license- � / )"It 1 q or designee ?-m-16 Date AFTER APPROVAL BY THE CITY CLERK YOU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO MORE THAN ONE YEAR FROM THE DATE LISTED BELOW. Sign a of City Clerk or designee 3-3ef -/ Date Office Use Only - — i Approved application DCI report State certified driving record - Website update aene IDRrveaosEn Ptszoiaamended. DOG 03/2015 oaMr 22. 2016. 4: 30 PM CebDiv of Criminal Investigation _.. a_STATE OF • WA ��{�IOy1R��11,c�HistoryRecord 0eJ� a Request Form Tot tows DIvlslon o(Crlminel Invoatlgation $tlppOrt WorationsBureaa, I" Floor 215 9,7'h street Des Moines, Iowa 50319 (5I5) 725.6066 (515) 7256080 Fax Z 4/_ / (FAX)3193362NO 0 19 1 P.1/3 r.��l/002 DCI Account Number, 9967-F (if applicable) From; Yellow Cab of lows City azo Iowa City, 1A. 52244 (319) 338.9777 Phonal Faxt (319)339-7302 bale ' ❑)FOrnale G vraiverttvor'mation: Without a eigncd waiver from the eabJect of the regpast, p Complgte grlminal history record may not be relearabie, per Code ollgwa, Chapter 692.2, For ca alato criminal haatory,reeord ]nformation, as allowed by taw, always Obtain a waiver dlanaturo from the fublpri nr tk..,.,.,.... Wal ver ReleaSs; I hereby Itvo ponniadion for the above rrquaang olltctel to conduct an Iowa odminel hlstoty record ebeok whh tho bivision of cflminel 1av1111ga11op (DCI), Any odminal hhtory data oenacmint me that It In11mined by the DCI may Ito 1911m4 ar allowed by law. Waiver Signature: (DCI Lao only) As of 3 a search of the provided name and date of birth revea1e4; ❑ No Iowa Criminal History Record fowtd with DCT `� c ,{ r.; LTJ Iowa Criminal History Record attaohed, DCI # � Q t r z.3 )XI initialA't'~' oa r DCI -77 (08!25/10) Received Tine Mar, 21. 2016 3:26PM No. 0196 Ma r. 22. 2016 4:30PM Div of Criminal Investigation No, 0 19 1 IOWA CRIMINAL HISTORY MISDEMEANOR CONVICTIONS ONLY Cl 00482290 PAGE 1 OF 2 001: 00482290 DATE PRINTED- 20160322 NAME; SURTON,CAMRRON LEE DO8 SEX RAC HGT WGT EYE HAIR SKN POE 19760424 M W $09 175 BLU HRO FAR IA ADDITIONAL IDENTIFIERS CCH RECORD ** 01 ARRESTED 19940704 AGENCY: IA0520100 CORALVILLE PD CHARGE NO- 01 IA STATUTE IA124-401-3 POSSESS SCHEDULE I/MARIJUANA TRK# 007541901 COURT DISPOSITION AGENCY: IA052015J JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE: IA124-401-3 POSSESS SCHEDULE 1/MARIJUANA CHARGE CLASS: MISDEMEANOR CONVICTION TRK#; 007541901 SENTENCE FINE $250 COURT COSTS $75 02 ARRESTED 19941125 AGENCY: IA0520000 JOHNSON CO $0 CHARGE NO- 01 IA STATUTE IA321J-2 OWI TRK$ 012452301 COURT DISPOSITION AGENCY: IA052015,7 JOHNSON CO DIST COURT COUNT NO- 01 IA STATUTE; IA321J.2 OPER VEH WH INT OWI CHARGE CLASS: MISDEMEANOR CONVICTION TRK$: 012452301 SENTENCE DEFERRED JUDGEMENT COMMUNITY SERVICE 50H JAIL 50 REVOKED COURT DISPOSITION AGENCY- IA052015J JOHNSON CO DIST COURT COUNT NO- 02 IA STATUTE- IA321-216-2 DRIVE WHILE REVOKED CHARGE CLASS; MISDEMEANOR CONVICTION TRK#: 012452302 SENTENCE FINE $250 03 ARRESTED 19990522 AGENCY: IA0570100 CEDAR RAPIDS PD CHARGE NO- DISP RPV DATE 19940818 19940818 DISP EFF DATE 19950320 19950320 19970717 19970717 - 1.0 DISP EFF DATE :' 19950320 E. P. 2/3 Mar.22• 2D16 4,30PM Div of Criminal Investigation No. 0191 P. 3/3 DCI 00482290 PAGE 2 OF 2 01 IA STATUTE IA321J-2-2-B OWI 2ND OFFENSE TRK$ 5003.6901 COURT DISPOSITION AGENCY: IA057015J LINN CO DIST COURT COUNT NO- 01 IA STATUTE: IA321J-2B OWI 2ND OFFENSE CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 500346901 SENTENCE PLEAD GUILTY DISP EFF DATE JRI "Ali,7D 19990025 FINE 19990825 $1500 19990025 COURT COSTS 19990825 04 ARRE$TED 20000701 AGENCY: IA0780000 POTT CO SO CHARGE NO- 01 IA STATUTE IA321J-21 DRIVE WHILE DENIED OR REVOKED TRX# 800328701 COURT DISPOSITION AGENCY: IA078015.7 POTT CO DIST COURT COUNT NO- 01 IA STATUTE: IA321.218 DRIVING WITH SUSPENDED LICENSE CHARGE CLASS: MISDEMEANOR CONVICTION TRK#: 800328701 SENTENCE DISP EFF DATE PLEAD GUILTY 200007D3 JAIL 2D 20000703 AN ARREST WITHOUT DISPOSITION IS NOT AN INDICATION OF GUILT, THIS RECORD MAINTAINED BY THE XOWA DIVISION OF CRIMINAL INVESTIGATION, BUREAU OF IDENTIFICATION IS A PUBLIC RECORD BUT CAN ONLY BE RELEASED TO NON -LAW ENFORCEMENT AGENCIES BY THE DCI, IN THE ABSENCE OF FINGERPRINTS FOR POSITIVE IDENTIFICATION THIS RECORD IS BASED ON INFORMATION FtfRNISHED. WE CANNOT CONFIRM OR DENY THAT THE RECORD COVERS THE SUBJECT OF YOUR INQUIRY, DIVISION OF CRIMINAL INVESTIGATION 4u• r�'��410WADOT :°MART R 15ii;�tr� I t4 .iTiiirit�i E�Eil�fr# VVLyW iowadot gov Office Of Driver services PO Box 9204 8 Gies Molftes, L# 50376-92134 P#taae: 5i5 244-?ai 24 800-532-1121 1 �:aK� 515-239-1837 www. iaaradot.gov Inquiry Date: Customer Name: Address: Certified Abstract of Driving Record 3/29/2016 DL/ID #: 359KK2073 (IA) CDL Permit Class: None 4698203 Class: D Burton, Cameron Lee Audit #: 5685743 311 W DOUGHERTY DR Issue Date: 12/15/2011 City/State: LONE TREE, IA Convictions Expiration 04/24/2017 Date: Endorsements: 3 CDL Permit Issue None Date: CDL Permit 527557749 Mailing PO BOX 411 Address: None Mailing LONE TREE, IA City/State: 527550411 Date of 4/24/1976 Birth: EXP Sex: M Convictions Expiration 04/24/2017 Date: Endorsements: 3 CDL Permit Issue None Date: CDL Permit None Expiration Date: Restriction None CDL Permit None Endorsements: Office of Driver Services CDL Permit None Restrictions: ELG ID Status: EXP Restrictions: NONE DL Status: VAL Restriction None CDL Status: None Supplement: Office of Driver Services Iowa Department of Transportation CDL Permit ELG Status: CDL Cert Status: None CDL Med Status: None History Information Citation Date Conviction Date ACV Explanation 06/29/2012_.. ... pr County ]Ur {07/18/2012 N82 Improper Backing Johnson SIA Name: Burton, Cameron Lee DL/ID: 359KK2073 Pursuant to Iowa Code §321.10, 1, Melissa Spiegel, 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, e.a In witness whereof, I have caused my signature and the seal of the Department to be set upon this�tiocumentJ'"at Ankeny; Iowa this date: C" b........,&"tt 3/29/2016 _.. IOWA''ao, D. 0. T. J f B.... Office of Driver Services Iowa Department of Transportation