DOUGLAS FREDERICK JR. - EXP 12/2014 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 YeIm.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.(5.02.010 C.)
Fingerprinting Fee$5.00 (5.02.030 A.l.)
Submit photographs with application- Three recent photos must be submitted with application. (lx application,lx police
dept,lx attach to license when issued)
rale_
Driver's
Driver's Name' S A A. IL.1e.. Phone numbs �pS--6Z1
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Driver's Address 53 A ANcrRickC City, and lipcode
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Mailing Address PC) X Z,L' City State and Zipcode "%LI On I
Valid Washington State Drivers License Number F�D Ntz..4'1 (5.02.030)
Vehicle License Tag/Plate Number G- ).2 &0
Proof of Ownership ii
Birthdate 0.3 I lelMust beat least 18 years old.
Proof of Insurance `
Business Nome and Address ` \\A City,State and ZiprodelsekW1 WvA
Mailing Address\ 0L1 City,State and Zipcode 11'1 , (Ai►'}-C1 '7
Washington State 1161# U{12_ k.36 (..v'�S
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? ki0
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?
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.
I certify my statements are tru and accurate.My signature aut !rims the City of Yelm to verify any information including a driver's
abstract L,
Signa • ' Date 1 - 1 -
-
WATCH Search Results-No Match - Washington State Patrol Page 1 of 1
Thursday, January 02, 2014
6i -11
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WASHINGTON ACCESS TO CRIMINAL HISTORY
Web Search No Record Found Report
Washington State Patrol
Identification and Criminal History Section
P.O. Box 42633
Olympia, Washington 98504-2633
Telephone (360) 534-2000
THE FOLLOWING WEB SEARCH NO MATCH FOUND REPORT
IS FURNISHED FOR OFFICIAL USE ONLY
This report was generated from a transaction run on 01/02/2014 at 14:41
Conviction Criminal History RCW 10.97.050(1)
Pursuant to the purpose of inquiry, NO Record was found in the Washington State Criminal
History Repository based on the descriptors provided:
FREDERICK,DOUGLAS A DOB 03/17/1988 SEX M RAC U
This may mean that the person you searched for has no criminal conviction record OR that your
search criteria did not match the spelling of the person's name or date of birth.
Positive identification or non-identification in the Washington State Patrol's database, can only
be determined by fingerprint comparison.
https://fortress.wa.gov/wsp/watch/Inbox?rsPage=detail&LocalIndex=0 01/02/2014
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MOD tYYYY)
7. 12131/2013
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___
�,__r_
Kelly Ray Foster
DBA Kelly KalbINSURER B.
P.O.Box 1761 INSURER C:
INSURER D:
Yelm,WA 98597
INSURER E:
COVERAGES
THE POUCIES 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POUCIES.AGGREGATE UMI TS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN SR ADD'L POLICY EFFECTIVE POUCY EXPIRATION LIMITS
LTB�IISRD TYPE OF INSURANCE POLICY NUMBER DATE MEDDDA'Yl DATE itAKEDDtYYI
GENERALUIBILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABIUTY
DAMAGE SO RENTED
COcure
PREMISES occurencel.............b .........................._...........................,
CLAIMS MADE f-1 OCCUR MED EXP(Anyone person) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
GEN_AGGREGATE LIMIT APPLIESPER: PRODUCTS-COMP/OP AGG $ _
POLICY r LOC
A N AUTOMOBILE LIABIU TY CAP625481301 07116/2013 07/16/2014 COMBINED SINGLE LIMIT
ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY $ 100,000
X SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY $ 300,000
NON-OWNED ALTOS (Per accident)
PROPERTYDAMAGE $ 25,000
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ _
ANY AUTOOTHER THAN EAACC $
AUTO ONLY: AGG $
EXCE SS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE
_ DEDUCTIBLE
RETENTION $ $
WC STATU- 0TH-
WORKERS COWEHSATIOII AND TORYIIMITS FR
EMPLOYERS'UABIUTY
E,L.EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERAIEMBER EXCLUDED? E I.DISEASE-EA EMPLOYEE $
It yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
A UIM CAP625481301 07/16/2013 07/1612014 25/50110
DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLE S!EXCLUSIONS ADDED BY ENDORSE MEAT 1 SPECIAL PROVISIONS
2001 MERCURY SABLE IMEHM55S61G601581
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 110 OBUGATION OR LIABILITY OF ANY NI11D UPON THE INSURER,ITS AGENTS OR
Olympia,WA 98507 REPRESENTATIVES.
AUTHO' ?'"''X' ESEIITATIVE
O• (KKY)
ACORD 25(2001108) OACORD CORPORATION 1988
Printed by KKY on December 31,2013 at 09:04AM
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may
require an endorsement.A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s),authorized representative or producer, and the certificate holder,nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
I
ACORD 25(2001108)
Printed by KKY on December 31,2013 at 09:04AM
•• WASHINGTON STATE DEPARTMENT OF
.LICENSING 956YFO
04/23/2013 Vehicle Registration Certificate
License plate Plate Issue date Tab no Reg expiration Value code Year Mo reg Mo gwt Pwr Use Mod yr Make Body
956YFO 01/2009 G123960 04/19/2014 21585 2001 12 G CAB 2001 MERC SAB4D
Vehicle ident(VIN)/Serial no Res co Scale wt Seats Model BT Gwt Gwt st Gwt exp Fleet Equip
1MEHM55S61G601581 27 3232 SL 4D
Prey plate Filing TBD RTA Tax Subagent GwtNeh wt Other Total fees Gwt cr
<32899 $3.00 $5.00 $10.00 $30.75 $48.75
KELLY FOSTER DBA
KELLY KAB
PO BOX 1761
YELM WA 98597
X
Signature of regist- wner(s) Signature of registered owner(s)
Comments:
USE TAX WAIVED: GIFT-COLOR-GRAY- DISPLAY TAB ON BACK LICENSE PLATE ONLY- FRONT PLATE IS STILL
REQUIRED.
11/1111
Validation code 03342203131130423130001038147RPT ID: AREGPR-1 This certificate is not proof of ownership.
VehicleRegistration(R/10/12)E
TD-420-802(R/1/12)Page 1 of 2
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