DUSTIN ROE - EXP 12/2015 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 renewa/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 on 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,l x police
dept, lx attach to license when issued)
Driver's Name E O Phone number 360•-510--/3o
Driver's Address/.S.-S Be/Y, Vk,/sey D4) ff City,State and Zipcode YP/,j V✓c, 9YS97
Mailing Address SCLrr .-' City,State and Zipcode
Valid Washington StateDrivers License Number RO/ ( 0E IL/2_ 0 F (5.02.030)
Vehicle License Tag/Plate Number A C 6 1 y y -
Proof of Ownership
Birthdate 51'P 6 /4.6 Must be at least 18 years old.
Proof of Insurance
Business Name and Address .Q\\k-\\c. 2) City,State and Zipcode fn JA- 9.
MailingAddX `�
ress � City,State and Zipcode\-k AA\ I.CJf--ekt5t'r7
Washington State OBI#
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? /i/ • l:
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? V_
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
cs
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 / Dote O3 pt; 6_0/S
/! I
r
-'"" Vehicle Registration Certificate Nt[}I44J
• ' f , 06/21/2014
License plate I Plate issue date Tab no 1 Reg expiration Value code Year Mo reg Mo gwt 1 Pwr` Use I Mod yr { Make i Body
i AEB1445 I 06/2011 T301684 (06/20/2015 21460 2003 12 I G CAB! 2003 MERC SAB4D i
Vehicle'dent(VINt/Serial no Res co Scale wt Seats] Model BT Owl Owl st Owl exp Fleet i Equip f
1MEFM50U83G626324_1 27 3202 ( SG 4D ,
Prey plate I F irg TBD 1 RTA Tax Subagent GwtNeh WI Other Totale s Gwt cr
t 011SET I $3.00 $5.00 $10.00 $30.75 $48.75
' l°µ
i ; -,, $
FOSTER.KELLY RAY DBA, ., , �,
KELLY KAB
PO BOX 1761
YELM WA 98597
}
Signature o'registered owner(s) Signature of registered owner(s)
Comments:
COLOR-GREEN-DISPLAY TAB ON BACK LICENSE PLATE ONLY-FRONT PLATE IS STILL REQUIRED.
'.:1;, ' 1
' i 2 1
Validation code 01342204141720621140007040761 ' ; �! „
RPT ID: AREGPR-1 This certificate is not proof of ownership. '" I,‘,
VehicloRegistraiion(Rr10/17)E
0
ACORD
® CERTIFICATE OF LIABILITY INSURANCE DATE 7/7/2014
PRODUCER (206)420-4270 FAX: (206)420-3284 7/7/2014
Key Insurance LLC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
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
NsuRED INSURERS AFFORDING COVERAGE
NAIC#
INSURER k Gateway Insurance Company
Kelly Ray Foster, DBA: Kelly Kab
P.o. Box 1761 INSURER B:
INSURER C:
Yelm WA 98597 INSURER D:
rereill
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
MAYPOLICIES.PERTAINAGGREG,THE ATE INSURANCELIMITS AFFORDEDSHOWNMAY BYHAVE THEBEEPONLICIESREDUCED DESCRIBEDBYPAID HERECLAIMINS,IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
INSR •;
TRT POLICY NUMBER fl
POLICY EFFECTIVE POLICY EXPIRATION
�' I.<t g •. ,.1 ��
GENERAL LIABILITY LIMITS
COMMERCIAL GENERAL LIABILITYim EACH OCCURRENCE $
II CLAIMS MADE f J OCCUR Eirempaitm $
1111MED EXP An one. rson $
IIPERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
is
PRO- ■ LOC PRODUCTS-COMP/OP AGG $
AUTOMOBILE LIABILITY
■ANY AUTO COMBINED SINGLE LIMIT
iiALLOWNED AUTOS11
(Ea accident) $
625481901 7/16/201'4 7/16/2015
SCHEDULED AUTOS BODILY INJURY
FIIREU AUTOS
(Per person) $ 100,000
INNON-OWNED AUTOS BODILY INJURY
(Per accident)
S.
300,000
PROPER(Per TY DAMAGE
GARAGE LIABILITY
PROP TY $
25,000
III
GA ANY AUTO AUTO ONLY-EA ACCIDENT $
■ OTHER THAN EA ACC 'S
EXCESS/UMBRELLA LIABILITY AUTO ONLY:
AGG $
■ OCCUR I J CLAIMS MADEI
EACH OCCURRENCErlimilimmilm
AGGREGATE $
■ DEDUCTIBLE
■ $
1111RETENTION $ $
WORKERS COMPENSATION
I
AND EMPLOYERS'LIABILITY . ■� $
N
ANY PROPRIETOR/PARTNER/EXECUTIVE IY/ I
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L EACH ACCIDENT $
If yes,describe under
SPECIAL PROVISIONS below ELM
E.L DISEASE-EA EMPLOYE: S
OTHER E.L,DISEASE-POLICY LIMIT $
• 625481901 7/16/2014 7/16/2015 uim
A
25/50/10
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
2003 Mercury Sabi? iI-115FM50U83G626324
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
f a7Cb1-S @ C�Or.Wa•gp V
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30
State of Washington DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
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
ACORD 25(2009/01) Steve Jones/MIA y'/ 1/7./L �
ACORD INS025(200901).01 The ACORD name and logo are registered marks of ACORD CORPO N. All rights reserved.
• WATCH Search Results-No Match- Washington State Patrol Page 1 of 1
Friday, March 06,2015
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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 03/06/2015 at 14:35
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:
ROE,DUSTIN E DOB 09/06/1986 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.
111
https://fortress.wa.gov/wsp/watch/Inbox?rsPage=detail&Locallndex=0 3/6/2015
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