THOMAS MCMULLEN - EXP 12/2017 City of ye Cm
OCCUPATIONAL PERMIT APPLICATION
Permits issued by the City of Yelm are valid in Yelm, Olympia, Tum water, and Lacey.
New Permit Renewal (Permit # Y 141'al )
I hereby request a permit to work in the following business, trade or occupation in accordance with all
laws and/or ordinances governing such business, trade or occupation in the City of Yelm.(YMC 5.03)
IMPORTANT: For new permits, complete all requested fields. For renewals, complete those fields marked with a star
(*) plus any other fields containing information that has changed since your last application was submitted.
*PERMIT TYPE (Check one) ❑For-Hire Driver Locksmith ❑Solicitor
APPLICANT INFORMATION
*Full Legal Name: //
(F/M/L) ft '!' >�-, �V`i l� (1 '
Other Name(s) Used: (If additional space is needed, use the back of this page)
(F/M/L)
(F/M/L)
Sex ' *Date of Birth /0-1S/c'gq *Age SS# �3S�G?F- %yam
*Height *Weight -A7C) *Hair Color *Eye Color
Place of Birth ' t,/6.
Have you ever had an occupational permit suspended or revoked? ❑Yes ❑No
If, "yes," when and where
HOME ADDRESS (Do not use a P.O. Box for your street address, please)
*Street g i< ,rNr4s ter/ ! u> *City r<(7C�) 5t✓ *State __
*ZIP CI `r' � "1 *Phone(' S 2 `j- Cell
*Mailing address (dame
*email [ (-- .
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If you are applying for a Solicitor's Permit or a For-Hire Driver's Permit, complete the
appropriate Supplemental Information section that follows.
For any other type of permit, skip to the "Application Document Checklist" section.
SUPPLEMENTAL INFORMATION — SOLICITOR PERMIT APPLICANTS ONLY
YMC 05.03.200 Qualifications
1. Briefly describe the products or services for which you will be soliciting. „27 UIlJZe 41e... a � ,
ror- k Q/ / CG
2. Please list all vehicles you will be using in your business. (Use the back of this form for additional vehicles, if
necessary)
Vehicle 1 Vehicle 2
Year ?
Make
Model (I,
Color ,r QQrt
Plate# ?
State JJ.
Ownerk's/6/C�
Vehicle 3 Vehicle 4
Year
Make
Model
Color
Plate#
State
Owner
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• CERTIFICATION
Under penalty of perjury, I swear that all information contained in this application is true, accurate and
complete to the best of my knowledge and belief. I also hereby authorize the City of Yelm to conduct
any reasonable inquiries, including examination of my criminal history, necessary to verify the
information I have provided and determine my fitness for the permit for which I have applied. I
understand that the City may, at its expense, conduct additional criminal history checks on me at any
time while I hold an occupational permit issued under YMC 5.03, and I hereby consent to such checks.
Signature '�.�k %r ,4zui& Date i-(7)6- Do/7
❑ I request a copy of the criminal history data used to determine my fitness for a permit.
City use only below this line
Date Received II ' ii 1 Reviewed By _` ' Review Date i t I
cpproved ❑Denied Reason: ❑ ncomplete application ❑Criminal record
❑Prior permit revocation ❑False information
005.03.060 CI Other (specify)
`Fees paid: Permit# I - 005 ❑Base fee refunded: Date
❑Permit ID completed ❑Applicant notified By Date
CI Permit fee only (non-fingerprint renewal)
Page 9 of 9
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CaWASHINGTON STATE DEPARTMENT OF CERTIFIED
m LICENSING Driving Record - MCMULTW137PN
Abstract of Driving Record-Employment
This information is current as of 1/25/2017 11:35:46 AM
Driver information Driver license status
PIC MCMUL-TW-137PN Status Clear
Name McMullen,Thomas William Issued 1/31/2014
Gender Male Expires 10/15/2018
DOB 10/15/1987 Original issue date 8/31/2004
PDL C Corrective Lenses- Issued 1/14/2003
Expired 10/15/2007
Original issue date 1/14/2003
Collisions ------- 4,1':-;;;1.:'44
Accident #of #of #of Veh At
date Description Accident report# vehicles injuries fatalities Case# Vehicle class type fault
3/25/2015 Moving E411367 2 0 0
--- ----------------------- ----
We are committed to providing equal access to our services. If you need accommodation,please call 360-902-3900 or TTY 360-664-0116.
If you have questions regarding your driving record,please call Customer Service at 360-902-3900. Page 1 of 1
TYPE OF TRANSACTION: NFUF
DATE TRANSACTION INITIATED: 02/11/2017
TRANSACTION CONTROL NUMBER: WA4099300008367273
NAME: MCMULLEN,THOAMS WILLIAM
EMPLOYER AND ADDRESS: YELM ORD
NON FEDERAL USER FEE ELECTRONIC RESPONSE
YELM ORDINANCE 5.03.045 RCW 35.21.920
SEARCH PARAMETERS:
NAME: MCMULLEN,THOAMS WILLIAM DOB 10/15/1987
SEX M RAC W
SEARCH MODE: Conviction
WA920676Z YELM POLICE DEPARTMENT DATE PROCESSED 02/15/2017
YELM, WA
PROCESSED BY: 13
PURSUANT TO PURPOSE OF INQUIRY, NO RECORD FOUND
02/15/2017
CRIMINAL RECORDS DIVISION
WASHINGTON STATE PATROL
WA920676Z
YELM POLICE DEPARTMENT
206 MCKENZIE AVE SE
YELM, WA 98597
PAGE 1 of 1
SUPPLEMENTAL INFORMATION — FOR-HIRE DRIVER PERMIT APPLICANTS ONLY
YMC 05.03.030 Qualifications (self disclosure)
Qualification Yes No
Have you had a valid Driver's License for the past two years?
1a If yes, in what state(s)? /
2 Are you 18 years old?
3 Do you have any physical or mental infirmities that may affect your driving?
4 Have you been convicted of three (3) or more moving violations during any one
(1) year period in the past five (5) years?
5 In the past five (5) years, have you been convicted of operating a motor vehicle
while under the influence of alcohol or drugs?
6 In the past five (5) years, have you been convicted of having physical control of
a motor vehicle while under the influence of alcohol or drugs?
7 In the past five (5) years, have you been convicted of negligent driving or
reckless operation of a motor vehicle?
8 In the past five (5) years, have you been convicted of vehicular homicide or
assault with a motor vehicle?
*All applicants must complete this section
APPLICATION DOCUMENT CHECKLIST
You need to do the following things before your application will be processed. Use this checklist to
make sure you have all the materials you need.
G Submit a copy of your driver's license or, if no current driver's license, your State-issued ID card.
❑ Provide an ID photo.
L- -lave your fingerprints taken at YPD.
LSubmit a copy of your complete driving record (for-hire driver/operator applicants only).
❑ Submit your completed and signed application form.
Pay your fees (cash, check or debit card).
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OTHER RECENT RESIDENCES
List all other states and cities where you have lived in the past five (5) years.
From To
State City (month/year) (month/year)
1 G!/- Ye/0c' ; 1y
2 (,c,/(4 /1"/)Lk (Limo, 9,01(;1-
3
,01(;3 (9/yr��.'� 11
4
5
BUSINESS INFORMATION (the business that is related to this permit)
*Business Name 1(64/knh
Business Owner/CEO C1 Q.iJ ❑ Applicant
Street City State
ZIP Phone Cell
Email Yelm Business License #
EMPLOYMENT HISTORY
Including your current employment, list the jobs you've held during the past five (5) years.
Job Title
1 , Employer City/StateFrom
/To
AliG,�� 39fl1?7 a pro-1_5. Q/11Y47, ‘e , / a0/4
2 6Vore.hoc.5Q 4J(12 fr,4.704.'S c w4 bn r>/ r►1 n.' Cr/79
3 :per,e�Q� c�afQ Win 1061
4
5
*CRIMINAL HISTORY (Self-disclosure)
In the past five (5) years, have you been convicted of any of the following offenses?
Offense Type Yes No
1 Any felony
2 Larceny/theft/vehicle prowling
3 Domestic violence
4 Fraud/Identity theft
5 Any drug-related crime
6 Any sex offense
7 Any crime against children or vulnerable adults
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