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CHARLES CLARK - EXP 12/2015 OFFICIAL USE ONLY • FORWARD TO P.D. APPLICATION FOR TAXI OR LIMOSINE FOR HIRE OR RENEWAL /1131 131 Please complete application to register with the City of Yelm.A renewa/application shall be mode in the same manner upon submittal of the fee and other information and items required far 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.l.) Submit photographs with application- Three recent photos must be submitted with application. (lx application,Ix police dept, lx attach to license when issued) Driver's Name (J. e( j L Phone number Driver's Address (( /0'1 10(P' (T. 5 rf City,State and Zipcodek7 I WS (�_C�� 7 Mailing Address v✓` t— City.State and Zipcode Valid Washington State Drivers License Number C, i-AS-(LL--. 1 i7(:- (5.02.030) Vehicle License Tag/Plate Number Proof of Ownership Birthdate CY3/v-3/7 9 Must be at least 18 years old. Proof of Insurance Business Name and Address \\\A\(--E:(_ City,State and Zipcode(r..V 1. 1.(J'4 c ~e'� Mailing Address lzQJX_ \ \ City,State and Zipcode Lemq Washington State IIBI# t-X)2 60,3 3 2 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 negli eqt driving,or of vehicular homicide or vehicular assault,with five years preceding the date of application for a license? A/h 2)Have you been convicted of three or mor moving violation during any one-year period within the five years preceding the date of the application for a license? ./(2) • 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 true and accu ate. y signature authorizes the City of Yelm to verify any information including a driver's abstract. 7Signature Date (c ® ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 7/7/2014 PRODUCER (206) 420-4270 FAX: (206)420-3284 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Key Insurance LLC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 5200 Southcenter Blvd, Ste 110 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. • Tukwila WA 98188 INSURED INSURERS AFFORDING COVERAGE INSURER k Gateway Insurance Company NAIL# Kelly Ray Foster, DBA: Kelly Kab P.o. Box 1761 INSURER B: INSURER C: Yelm WA 98597 INSURER D: COVERAGESrell 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. INSR •DD'L TR .D T • POLICY NUMBER POUCY EFFECTIVE POLICY EXPIRATION • .- .•• GENERAL LIABIUTY • • - u ••I' al LIMITS ■ COMMERCIAL.GENERAL LIABILITYIIII II uEACH OCCURRENCE ' 1111111111111111111 II CLAIMS MADE f I OCCUR M $ MED EXP(An one.-raw $ 1111PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE nIIIIIIIIIIIIIII ■ POLICY PRO- Ill PRODUCTS-COMP/OP AGG nIIIIIIIIIIIII AUTOMOBILE LIABILITY ■ANY AUTO CEO BIEDSINGLE LIMIT $ ■ALL OWNED AUTOSI accident) 625481401 7/16/2019 7/16/2015 © SCHEDULED AUTOS BODILY PDI person) $ ■ HIRED AUTOS 100,000 . NON-OWNED AUTOSII------------: BODILY INJURY (Per accident) $ 300,000 (Per• accldenlPROPERTY DAMAGE $ 25 000 GARAGE LIABILITY11 , Ia ANY AUTO AUTO ONLY-EA ACCIDENT $ • • OTHER THAN EA ACC 'E 119111111111 EXCESS/UMBRELLA LIABILITY AUTO ONLY: AGG ■ OCCUR F.]CLAIMS MADEI EACH OCCURRENCE AGGREGATE E IIDEDUCTIBLE $ 111RETENTION $ $ WORKERS COMPENSATION ■ RNIMIIIIIIIIIIIII AND EMPLOYERS'LIABILITY '_ E ', OFFICER/MEMBEER • i ANY /EXCLUDED?PARTNER/EXECUTIVE LY/N ■ ■.�'i (Mandatory In NH) - E.L EACH ACCIDENT IIIIIIIIIIIII If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-EA EMPLOYE: $ - OTHER E.L.DISEASE-POLICY LIMIT S 625481901 7/16/2014 A 7/16/2015 uim 25/50/10 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS 2003 Mercury Sable 11FM50U83G626324 CERTIFICATE HOLDER CANCELLATION faxbls@dor.wa.gov SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL State of Washington IMPOSE NO OBLIGATION OR LIABIUTY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Business Licensing Services P.0 Box 9034 Olympia, WA 98034 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 1/ ACORD 25(2009/01) Steve Jones/MJA y—,/ �.�/r/,� The ACORD name and logo are registered marks of ACORD RD CORPO- N. All rights reserved. .........,.......--•<,, , ,,... Vehicle Registration Certificate I-ktti 1440 . . 06/21/2014 1 License plate I Plate Issue date Tab no 1 Reg expiration Value code Year Mo reg Mn gwt I'.'w,I Use I Mod yi I Make i Body 1 AEB1445 i 06/2011 T30168406/20/2015 .,„„,......„ ., . J 21460 2003 12 I G I CAB 1 2003 i MERC i SAB4D i I Vehicle ident(VIM/Serial no Res co Scale wt Seats I Model ET Gwt Gal at Gat exp Fleet Equip 1 1 1MEFM50U83G626324 27 3202 1 SG 4D I Prey plate Filing TBD RTA Tax . Subagent GatNeh wt Other Tote'.fees Gat cr [ 011SET $3.00 $5.00 $10.00 $30-75 $48/5 i FOSTER.KELLY RAY DBAKELLY , •,..:, . PO BOX 1761 „-..'...r :',..-'.,,- ,- .. ...... y ' _ YELM WA 98597::PV:,`;' - ...- :..:L...4.''.” -.,: :: ''': .P,....-.-.T.:(,,,--0). ' —-c-,,••••,;':=:!...4.,::;..7y,,..,..-• ' g.:g'4:','-',' '- "--."•.-07,:',-.. " . -,. 1,:t,,,,. ,,,„ :'---.-.- ----AU.1, :-..:e?:-, . . .W.„,,,: . --', ,', • ,.. ,,?.“. r, ,,' .,- • - "- ,, O.,..'.:::::,••,.,kc. ',-, .. ' :1 ,','?-','•:.?'ir.:•.,`,.',:.'..'I- --:--,;'-'''!m"•z-'''';'; '. ,'•-, ''''' ,"-', . ,<I' • '••2 1,,,. ,,.:*".•„1":' :!;f2:0,,*;-'4.:-A,--;,>. ,',' :'.::•.,...,..J,.,:::::.•„-,;:.:...--'-' '''' z.-,2, , . .r, :;:,15, ,t;,:i-',:,;-.• .'-::'::::'.-QW, •1,- ''',.• ''.:.•.:".'-•'•.' :,:-..."-,: -• ::;"-''i.,,k'''' '';'1'1''''''',?'''&11,k,'''• ''-- ''''' ''''!'-• X .... x_. _. .. . Signature Signature of registered owner(s) Signature of registered owner(s) Comments: COLOR-GREEN-DISPLAY TAB ON BACK LICENSE PLATE ONLY-FRONT PLATE IS STILL REQUIRED. -"'4'.'.-::'!;'7,,-.-, . ".,„-.:,•4• 45..:--:-,- ;'4,5'..iiti•:•."•"a,,,•-'. -.,,,,-----`,r,,,,i' •',,,,,:,44:,, ;',.il,i'4,,,',`, " -..'-',,,Vn,--;:.:,,-f:-,•,•-•,,4'7Z.',, - '•-''' '• '-''''''''Al''',••:,- ' ''',':'": • ,‘ii $,,,4',:1, v=' , , '::-,,:. ',.- - ''':,-:1;rtkeZk :':-. .-15V,,., ' - "..' : •,' '--, - ,,,:...•: Illt411.1 '1'' ,:i ; '' ' • ! :1 •t" ), , . Validation code 01342204141720621140007040761 ,., ,, '. 'is„ • : e , ..,,at 1 a i •• • RPT ID: AREGPR-1 This certificate is not proof of ownership. Vehk-leRegistration(R/10112)E ,... ' • • • • ' WATCH Profile Management - Washington State Patrol Page 1 of 3 Friday, March 06, 2015 km u• 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 03/06/2015 at 11:55 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: CLARK,CHARLES L DOB 03/03/1979 SEX M RAC U WASHINGTON STATE CRIMINAL HISTORY RECORD FOR SID/WA21229041 WASHINGTON STATE PATROL IDENTIFICATION AND CRIMINAL HISTORY SECTION P.O. BOX 42633 OLYMPIA, WASHINGTON 98504-2633 ******************************************************************************* CRIMINAL HISTORY INFORMATION AS OF 03/06/2015 ******************************************************************************* 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: CLARK,CHARLES LEVI DOB: 03/03/1979 https://fortress.wa.gov/wsp/watch/Inbox?rsPage=detail&CVIndex=0 3/6/2015 WATCH Profile Management- Washington State Patrol Page 2 of 3 SID NUMBER: WA21229041 DOC NUMBER: ******************************************************************************* PERSON INFORMATION ******************************************************************************* SEX RACE HEIGHT WEIGHT EYES HAIR PLACE OF BIRTH CITIZENSHIP M W 602 230 BRO BRO CO US OTHER NAMES USED OTHER DATES OF SOC SEC MISC NUMBER BIRTH USED NUMBER ******************************************************************************* CONVICTION AND/OR ADVERSE FINDING SUMMARY ******************************************************************************* 0 FELONY(S) DISPOSITION DATE 1 GROSS MISDEMEANOR(S) DRIVING UNDER THE INFLUENCE 12/20/2002 0 MISDEMEANOR(S) 0 CLASSIFICATION(S) UNKNOWN ******************************************************************************* **** 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 1 DATE OF ARREST: 10/07/2002 NAME USED: CLARK,CHARLES LEVI CONTRIBUTING AGENCY: WA0340000 THURSTON COUNTY SHERIFF LOCAL ID: Z0050780 PCN: 766732216 TCN: N/A ARREST OFFENSES I DISPOSITION CONTRIBUTOR OR RESPONSIBLE AGENCY: WA034013J THURSTON COUNTY DISTRICT COURT I COURT CASE NO: C00011531 I STATUS: GUILTY I 07644 DRIVING UNDER THE INFLUENCE RCW: 46.61.502 GROSS MISDEMEANOR https://fortress.wa.gov/wsp/watch/Inbox?rsPage=detail&CVlndex=0 3/6/2015 ' WATCH Profile Management-Washington State Patrol Page 3 of 3 I STATUS DATE: 12/20/2002 I SENTENCE: SENT. DESC. : CHG 01: FINE-1005.00, JAIL- 365 DS SUSPENDED 355 DS ******************************************************************************* STATE DEPARTMENT OF CORRECTIONS ******************************************************************************* NO KNOWN CUSTODY HISTORY INFORMATION ******************************************************************************* NO KNOWN SEX/KIDNAPPING OFFENDER REGISTRATIONS ******************************************************************************* NO KNOWN APPLICANT DETAILS ******************************************************************************* ******************************************************************************* NO KNOWN MONITORED POPULATION REGISTRATION TRACKING INFORMATION ******************************************************************************* ******************************************************************************* 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 WSP CRIMINAL HISTORY & FINGERPRINT TRAINING WWW.WSP.WA.GOV/_SECURED/IDENT/RESOURCE.HTM 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&CVIndex=0 3/6/2015 ix '.. _et �W x - 6 a ►O E a m V .yo�� • )144 l'OW N Zodi S M I., M QN q 11414 (1J W h 5 V q• w 2 1