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JEROME D. GODSHALL - EXP 12/2013 02)7vs-', OFFICIAL USE ONLY FORWARD TO P.D. APPLICATION FOR TAXI OR LIMOSINE FOR HIRE OR RENEWAL Please complete application to register with the City of Ye1m.A renews/application shall be made in the same manner upon submittal of the fee and other information and items required for the initial application,including photographs.(5.02.030 B) Application Fee:$35.00 PAID PROOF REC'D-Waived if applicant has established an approved license from another Thurston County city. Proof of the paid for-hire license for the same time period and background check must be shown and verified.(5.02.070 C.) Fingerprinting Fee$5.00 (5.02.030 A.1.) Submit photographs with application- Three recent photos muss be submitted with application.__(1 x application, lx police dept, lx attach to license when issued) Driver's Name . tr6ill P 120i h e l 6-0,4 i 1.i 4h i t Phone number 3(j 0 4 1 A- i-1 2 7 Driver's Address 1.6 pox f`l 1.)r c tt_City,State and Zipcode CI/ c-76 R ci i'1� t'e r L�c, Mailing Address P.O. 13 0 A' 7`#2 City State and Zipcode i h r r Y` i-v c-7 6 Valid Washington State Drivers license Number (7Od S i,J () 'Z. 5.-'0 t 2, (5.02.030) Vehicle license Tag/Plate Number Proof of Ownership Birthdate —1 ) 1 7 l Must be at least 18 years old. Proof of Insurance ` Business Name and Address Q\X,14\ 1 V,.CJ City,State and Zipcode'4 `v Q t(41'l ' �Y41 Mailing Address VC..) 60X t71(,t City,State and Zipcode \ e ff'1� IAA ` n Washington State UBI# i1�t7Z Q33 Gobs l 1)Have you been convicted of a felony,or of operating a motor vehicle while under the influence of intoxicating liquor or drugs or of being in actual physical control of a motor vehicle while under the influence of intoxicating liquor or drugs,or of reckless driving or negligent driving,or of vehicular homicide or vehicular assault,with five years preceding the date of application for a license? rvO 2)Have you been convicted of three or more moving violation during any one-year period within the five years preceding the date of the application for a license? tY c 3)Are you at least 18 years with no physical or mental infirmity,which jeopardizes the ability to operate a for-hire vehicle.No person shall drive a for-hire vehicle,including limousines,within the City without first obtaining a license therefore from the City. y f 5 I certify my statements are true and accurate.My signature authorizes the City of Yelm to verify any information including a driver's abstract. Signature 7 ere Vh(? God y-‘„M 11 Date I,/ I /'/ 13 { I Rapsheet for Candidate WA17221149, *GODSHALL,JEROME DANIEL , run 2013-01-... Page 1 of 4 ® n.wATCH S®GTGNSTA WASHINGTON ACCESS TO CRIMINAL HISTORY Web Search Transcript Washington State Patrol Identification and Criminal History Section P.O. Box 42633 Olympia, Washington 98504-2633 Telephone (360) 534-2000 This report was generated from a transaction run on 01/18/2013 at 14:56 Conviction Criminal History RCW 10.97.050(1) Pursuant to the purpose of inquiry, A possible match was found in the Washington State Criminal History Repository based on the descriptors provided: GODSHALL,JEROME D DOB 09/18/1979 WASHINGTON STATE CRIMINAL HISTORY RECORD FOR SID/WA17221149 WASHINGTON STATE PATROL IDENTIFICATION AND CRIMINAL HISTORY SECTION P.O. BOX 42633 OLYMPIA, WASHINGTON 98504-2633 ******************************************************************************* CRIMINAL HISTORY INFORMATION AS OF 01/18/2013 ******************************************************************************* NOTICE THE FOLLOWING TRANSCRIPT OF RECORD IS FURNISHED FOR OFFICIAL USE ONLY. SECONDARY DISSEMINATION OF THIS CRIMINAL HISTORY RECORD INFORMATION IS PROHIBITED UNLESS IN COMPLIANCE WITH THE WASHINGTON STATE CRIMINAL RECORDS PRIVACY ACT, CHAPTER 10. 97 RCW. POSITIVE IDENTIFICATION CAN ONLY BE BASED UPON FINGERPRINT COMPARISON. BECAUSE ADDITIONS OR DELETIONS MAY BE MADE AT ANY TIME, A NEW COPY SHOULD BE REQUESTED FOR SUBSEQUENT USE. WHEN EXPLANATION OF A CHARGE OR DISPOSITION IS NEEDED, COMMUNICATE DIRECTLY WITH THE AGENCY THAT SUPPLIED THE INFORMATION TO THE WASHINGTON STATE PATROL. THIS CONVICTION RECORD INCLUDES INFORMATION FOR WHICH A PERSON IS CURRENTLY BEING PROCESSED BY THE CRIMINAL JUSTICE SYSTEM. ******************************************************************************* MASTER INFORMATION ******************************************************************************* NAME: GODSHALL,JEREMY D DOB: 09/18/1979 SID NUMBER: WA17221149 DOC NUMBER: https://fortress.wa.gov/wsp/watch/Inbox?rsPage=detail&CVlndex=0 1/18/2013 Rapsheet for Candidate WA17221149, *GODSHALL,JEROME DANIEL , run 2013-01-... Page 2 of 4 ******************************************************************************* PERSON INFORMATION ******************************************************************************* SEX RACE HEIGHT WEIGHT EYES HAIR PLACE OF BIRTH CITIZENSHIP M W 600 170 HAZ BRO CA US OTHER NAMES USED OTHER DATES OF SOC SEC MISC NUMBER GODSHALL,JEREMY DANIEL BIRTH USED NUMBER GODS HALL,JEROME GODSHALL,JEROME DANIEL ******************************************************************************* CONVICTION AND/OR ADVERSE FINDING SUMMARY ******************************************************************************* 0 FELONY(S) DISPOSITION DATE 1 GROSS MISDEMEANOR(S) DRIVING UNDER THE INFLUENCE 01/03/2007 2 MISDEMEANOR(S) DRIVING WHILE LIC SUSP OR REVOKED-3 06/09/1999 DRIVING WHILE LIC SUSP OR REVOKED-3 04/01/1999 1 CLASSIFICATION(S) UNKNOWN MALICIOUS MISCHIEF-3 02/12/1999 ******************************************************************************* **** NO KNOWN DOC SUMMARY INFORMATION **** ******************************************************************************* ******************************************************************************* CRIMINAL HISTORY INFORMATION ******************************************************************************* THE ARRESTS LISTED MAY HAVE BEEN BASED ON PROBABLE CAUSE AT THE TIME OF ARREST OR ON A WARRANT. PROBABLE CAUSE ARRESTS MAY OR MAY NOT RESULT IN THE FILING OF CHARGES. CONTACT THE ARRESTING AGENCY FOR INFORMATION ON THE FORMAL CHARGES AND/OR DISPOSITIONS. AN ARREST IS NOT A CONVICTION OR FINDING OF GUILT. ARREST 4 DATE OF ARREST: 01/20/2007 NAME USED: GODSHALL,JEROME DANIEL CONTRIBUTING AGENCY: WA0340000 THURSTON COUNTY SHERIFF LOCAL ID: Z0046733 PCN: 766905927 TCN: WA3400000100023192 ARREST OFFENSES I DISPOSITION CONTRIBUTOR OR RESPONSIBLE AGENCY: WA034013J THURSTON COUNTY DISTRICT COURT COURT CASE NO: C00579717 STATUS: GUILTY 0764400 DRIVING UNDER THE INFLUENCE RCW: 46.61.502 (5) GROSS MISDEMEANOR STATUS DATE: 01/03/2007 COUNTS: 1 https://fortress.wa.gov/wsp/watch/Inbox?rsPage=detail&CVIndex=0 1/18/2013 Rapsheet for Candidate WA17221149, *GODSHALL,JEROME DANIEL , run 2013-01-... Page 3 of 4 I SENTENCE: JAIL: 365 D, I JAIL SUS. : 364 D I FINE: $698.00 I ARREST 3 DATE OF ARREST: 02/02/1999 NAME USED: GODSHALL,JEROME DANIEL CONTRIBUTING AGENCY: WA0340000 THURSTON COUNTY SHERIFF LOCAL ID: B77890 PCN: 003695263 TCN: N/A ARREST OFFENSES I DISPOSITION CONTRIBUTOR OR RESPONSIBLE AGENCY: WA034013J THURSTON COUNTY DISTRICT COURT COURT CASE NO: C12834TC STATUS: GUILTY I 02191 MALICIOUS MISCHIEF-3 RCW: 9A.48.090 DOMESTIC VIOLENCE CLASS UNKNOWN STATUS DATE: 02/12/1999 SENTENCE: SENT. DESC. : CHG 01: FINE-250.00, JAIL- I 365 DS/SUSPENDED 355 DS, SUPV-2 YRS ARREST 2 DATE OF ARREST: 12/16/1998 NAME USED: GODSHALL,JEROME DANIEL CONTRIBUTING AGENCY: WA0210100 CENTRALIA POLICE DEPARTMENT LOCAL ID: 71882 PCN: 004019971 TCN: N/A ARREST OFFENSES I DISPOSITION CONTRIBUTOR OR RESPONSIBLE AGENCY: WA021011J CENTRALIA MUNICIPAL COURT COURT CASE NO: 56873 STATUS: GUILTY 07633 DRIVING WHILE LIC SUSP OR REVOKED-3 RCW: 46.20.342 (C) MISDEMEANOR STATUS DATE: 06/09/1999 SENTENCE: SENT. DESC. : CHG 01: FINE-550.00, JAIL- I 90 DS/SUSPENDED 60 DS ARREST 1 DATE OF ARREST: 12/01/1998 NAME USED: GODSHALL,JEROME DANIEL CONTRIBUTING AGENCY: WA0340000 THURSTON COUNTY SHERIFF https://fortress.wa.gov/wsp/watch/Inbox?rsPage=detail&CVlndex=0 1/18/2013 Rapsheet for Candidate WA17221149, *GODSHALL,JEROME DANIEL ,run 2013-01-... Page 4 of 4 LOCAL ID: B76728 PCN: 003722686 TCN: N/A ARREST OFFENSES DISPOSITION CONTRIBUTOR OR RESPONSIBLE AGENCY: WA034013J THURSTON COUNTY DISTRICT COURT COURT CASE NO: C51TC STATUS: GUILTY 07633 DRIVING WHILE LIC SUSP OR REVOKED-3 RCW: 46.20.342 (C) MISDEMEANOR STATUS DATE: 04/01/1999 SENTENCE: SENT. DESC. : CHG 01: FINE-250.00, JAIL- 90 DS/SUSPENDED 85 DS ******************************************************************************* STATE DEPARTMENT OF CORRECTIONS ******************************************************************************* NO KNOWN CUSTODY HISTORY INFORMATION ******************************************************************************* NO KNOWN SEX/KIDNAPPING OFFENDER REGISTRATIONS ******************************************************************************* ******************************************************************************* NO KNOWN APPLICANT DETAILS ******************************************************************************* ******************************************************************************* GLOSSARY OF TERMS IS AVAILABLE IN THE CRIMINAL JUSTICE TRAINING MANUAL (CJTM) LOCATED AT http://www.wsp.wa.gov/crime/crimhist.htm ******************************************************************************* RESOURCES ******************************************************************************* ADMINISTRATIVE OFFICE OF THE COURTS (AOC) WWW.COURTS.WA.GOV WSP CHRU CRIMHIS@WSP.WA.GOV OR (360) 534-2000 DEPARTMENT OF CORRECTIONS (DOC) WWW.DOC.WA.GOV WSP SOR UNIT (360) 534-2000 WSP CRIME LAB CODIS (206) 262-6020 RCW HTTP://APPS.LEG.WA.GOV/RCW/ LEGISLATION HTTP://APPS.LEG.WA.GOV END OF RECORD https://fortress.wa.gov/wsp/watch/Inbox?rsPage=detail&CVlndex=0 1/18/2013 ACORDCERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) M 0711312012 PRODUCER Phone:(206)420-4270 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Key Insurance, LLC HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 5200 Southcenter Blvd Suite 110 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Tukwila,WA 98188 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Gateway Insurance Company Kelly Ray Foster INSURER B: DBA Kelly Kab INSURER C: P.O. Box 1761 INSURER D: Yelm,WA 98597 INSURER E. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILSR ADM. POLICY NUMBER DATE IMMIDDIYYI POLICY DATE(MM/DD/YY) LIMITS LTR INSRi] TYPE OF INSURANCE GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurence) $ CLAIMS MADE OCCUR MED EXP(Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JFPRO LOC A N AUTOMOBILE LIABILITY CAP625481201 07/16/2012 07/1612013 COMBINED SINGLE UMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ 100,000 'X SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ 300,000 (Per accident) NON-OWNED AUTOS - PROPERTY DAMAGE $ 25,000 (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTOOTHER THAN EA ACC $ _ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ _. DEDUCTIBLE $ RETENTION $ _ $ - WORKERS COMPENSATION AND TORY UMITS ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ _ _ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER A UIM CAP625481201 . 07116/2012 07/1612013 25/50/10 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS 2001 MERCURY SABLE 1MEHM55S61G601581 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN Department of Licensing NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL P.O. Box 9034 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Olympia,WA 98507 REPRESENTATIVES. AUTHO ESENTATIVE ` (KKY) ACORD 25(2001/08) ©ACORD CORPORATION 1988 Printed by KKY on July 13,2012 at 03:02PM STOM STATE DEPARTMENT OF SENSING AEB1445 06/29/2012 VEHICLE REGISTRATION CERTIFICATE 'it Iss-Dt Tab-No Reg-Exp Val-Cd/Year Dep Mo-Reg Mo-Gwt Pwr Use Mdyr .45 06/2011 W208831 06/20/2013 21460/2003 1 12 G CAB 2003 Body VIN or Serial No Res-Co Sclwt Seats Model/BT Gwt Gwt-St Gwt-Exp Flt SAB4D 1MEFM50U83G626324 27 3202 SG /4D / / / / Prev-Plt Filing TBD 0000 RTA Tax Subagent Gwt/Veh Wt Other Total Fees Cash Gwt Cr 011SET $3.00 $5.00 $10.00 $30.75 $48.75 $48.75 FOSTER,KELLY RAY DBA KELLY KAB PO BOX 1761 YELM WA 98597 / ,' , —air IATURE OF REGISTERED OWNERS SIGNATURE OF REGISTERED OWNERS NTS: -GREEN - DISPLAY TAB ON BACK LICENSE PLATE ONLY - FRONT PLATE IS STILLREQUIRED. KS: S: 11/2011 ORIG TAXI §' i11 1 I`4 1 1 D: AREGPR-1 VALIDATION CODE 17341201121810629120022019953 111111111111111�THIS CERTIFICATE IS NOT PROOF OF OWNERSHIP RREdi8EGPR:2009/30/6.00001 (1) • hxe. et DLA [ rn �" tori nO C) it ),„„iOD0.m tz Iv ro to " y O N CAI cla o ...4 t KD V , wa)I-) C) Yrj A 00 01 n (.J J ry h-y 3 m`Q F-1 A1 ' y � � xgr ` ISM