DUSTIN ROE - EXP 12/2016 OFFICIAL USE ONLY
FORWARD TO P,D.
APPLICATION FOR TAXI OR LIMOSINE FOR HIRE OR RENEWAL / 3o if -
Please complete application to register with the City of Yelm.A renewo/application shall be mode 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.l.)
Submit photographs with application- Three recent photos must be submitted with application.`(lx application, I x police
dept, lx attach to license when issued)
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Driver's Name Uc.5.j n Phone number. )-9c'?—/30.
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Driver's Address /SSS Awiy V /e )` City,State and Zipcode ‘}4'1".""/ t/c-, 9s$9P
Mailing Address)53 S i9 'yak,icey it'1 City..State and Zipcode y.4#i
Valid Washington State.Drivers License Number G E e JE` L? f -12 U T (5.02.030) •
Vehicle License Tag/Plate Number (3 5
Proof of Ownership
/940
Birthdate G9/cc/ —ter Must be at least 18 years old.
Proof of Insurance
Business Name and Address 1~ c t`\ _ct\o City,State and Zipcode \I--4)\\/1A r 1),fo1-RC1 7
Mailing Address R9x (1(p ( City,State and ZipcodeyeA\/V LAJF‘ otE6T11
Washington State 1101# (602_g3z) (o?
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?
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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. s
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 � Date
lel/ pi i /
7Th
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WASIIINITil STATE DEPANTMENT Ni,
CE LICENSING
• Vehicle Registration•Certificate, E81445•
License'plate Plate Issue date Tab no: : *Reg expiration. Value Code'. Year Mo reg Mo gwt PWr ..Use Mod'yr.. Make Body.'
AEB1445 06/201:1,'' B413611'. 06/20/2016 21460 .20Q3 12 •,G •:CAS' : 2003' MERG. SAB4D ,
Vehicle ident'(VIN)/Serial no '. Res co Scale wt 'Seats.-"Model .Gwt st's-' '' :. Gwt:exp• Fleet Equip ' •
1 MEFM50U83G626324 27 . .3202;.•...• "SGp '
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Prey plate • Filing TBO '•:.ttTATax•• Se`rvico:f „4wt/yeh wt' Other Total tees Gwt cr •
`011SET $3,00. :..
� y. •?;, , •. .; •:$5:{�Q=_'.: 7r$1.0:;00 :$30:75. $48.75
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FOSTER KELL `RAY _ .." ,
• :KELLY KAIi' Y QB ` >gayx ` i`
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Signature:oft- stead own • .: ,
), "1 • i_ `�' _. Signature of registere4ownsT(s0~
Comments i'
COLOR-GREEN DISPLAY TAB.L .•BACK`LIOENSE PL TE:ONLY-FRONT PIATE.`IS STILL REQUIRED
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Validation code 033412011.51.830702150022012327. • ``i t:r1'.10;/ J
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RPT ID AREG •
PR-1 T_ h• is certificate•Is not proof of ownership.. : r {
VeiiicleRegistration[(R/8/1�4)E
10.420.902(R/1/12)page 1.of 2 . • • J.; •; • . '
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ACOR� INSURANCE DATE(MMIDD/YYYY)
.i` d CERTIFICATE OF LIABILITY 7/2/2015
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
TOP NOTCH INSURANCE SOLUTIONS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1100 Virginia St #211 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Seattle, WA 98101
(206)264-6267 INSURERS AFFORDING COVERAGE NAIC*
INSURED FOSTER, KELLY RAY INSURER A: National Indemnity Company020 87
DBA KELLY KAB INSURER 8:
PO BOX 1761 INSURER C:.
YELM, WA 98597 INSURER D::
I I INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EE E�����jjyy p���y pA�
IOfil
LIR M IL TYPE OF INSURANCE POLICY NUMBER OA01 MM10pMYVY)E I DATE( ID/YYYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE S
I COMMERCIAL GENERAL LIABWTY ! DAMA6E TO RtNTED
11PREMISES(Ea occurs/es) S
i CLAIMS MADE I OCCUR MED EXP(My one porton) 3
1
• PERSONAL S.ADV INJURY $
--J GENERAL AGGREGATE 3
GEM.AGGREGATE LIMIT APPLIES PER
�' PROOUCT8-COMP/OP AGG 3 I
('
7 POLICY Ia n LOC .
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
3
ANYAUTO (Es accident)
ALL OWNED AUTOS BODILY INJURY
X SCHEDULED AUTOS (Per person) : 100,000
A HIREDAUTOS 71APR322396 7/3/2015 7/3/2016 BODILY INJURY
NON-OWNED AUTOS • (Per occident) 3 300,000
PROPERTY DAMAGE
(Peraccidsrt) $ 25,000
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT I
ANYAUTO EA ACC $
OTHER THAI:
AUTO ONLY: AGO S
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE 3
OCCUR U CLAIMS MADE AGGREGATE 3
If
1_
DEDUCTIBLE
RETENTION 3 13
WORKERS COMPENSATION WWCC STATU- OTH -
-
AND EMPLOYERS'LIABILITY YIN TO Y LIMITS ER
ANY PROPRIETOR/PARTNEMXSCUTIVE E.L.EACH ACCIDENT 3
OfPICSR/ME?, ER EXCLUDED?
Mandatory In NMI E•L DISEASE-EA EMPLOYEE S
SPECIAL PROVISIONS below I E.L.DISEASE-POLICY LIMIT S
OTHER
A UIM SPLIT 71APR322396 7/3/2015 7/3/2016 $25/$50/$10
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES/EXCLUSIONS ADDEO BY ENDORSEMENT I SPECIAL PROVISIONS
EVIDENCE OF INSURANCE
2003 MERC VINS1MEFM5OU83G626324
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY of MO wove DESCIDElD rouC{RS sa CANCELLED=FORE The EXPIRATION
DEPT OF LICENSING • 30 DAYS WRITTENMASTER LICENSING SERVICE DATE THEREOF,THE ISSUING MUREX WILL ENDEAVOR TO AWL
PO BOX 9034 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 10 SHALL
IMPOSE NO OSLGATION OR LIABILITY Of ANY KM UPON THE INSURER,ITS AGENTS OR
OLYMPIA, WA 98507
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE f// v
1
I) ACORD25(2009/01) ®1988-2009 ACRD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Page 1 of 1
ErWAT
WA SHINGTON ACCESS TO CRIMINAL HISTORY
Web Search No Record Found Report
Washington State Patrol
Identification and Criminal History Section
P. 0. Box 42633
Olympia, Washington 98504-2633
Telephone (360) 534-2000 Option 2
THE FOLLOWING TRANSCRIPT OF RECORD
IS FURNISHED FOR OFFICIAL USE ONLY
This report was generated from a transaction run on 1/19/2016 at 9:21 AM
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 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.
https://fortress.wa.gov/wsp/watch/Home/PrintResponse?Search=2&PurposeCode=V&Que... 1/19/2016
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