ROSINA NEWTON - EXP 12/2017 City of yeCm
OCCUPATIONAL PERMIT APPLICATION
Permits issued by the City of Yelm are valid in Yelm, Olympia, Tumwater, and Lacey.
❑New Permit ❑Renewal (Permit#
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) enC,
Other Name(s) Used: (If additional space is needed, use the back of this page)
(F/M/L)
(F/M/L)
Sex F *Date of Birth \2— \cl - \ *Age L\ SS# ((0 -ct\ ctS
*Height 5 71 *weight aa *Hair Color rcX *Eye Color cv.-)'Th
Place of Birth ` e.0..1-A2 t \)-)`R
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 c)OR 4e 1 *City Net Y'sr\ *State C,..)rt
*ZIP q a6q-4 *Phone r aD L\-6 L,Li Cell 020(o X13 3(
3020 C1C1 0c131
*Mailing address (Lysame
*email votc-c -kki {isR "e , t.,nCucui\
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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 w y.e,tr \ 0—i. I i L1 i s�/ f
2 UJS��- A010 020 I L
3
4
5
BUSINESS INFORMATION (the business that is related to this permit)
*Business Name .1n ,r RuP( .c7 v\
Business Owner/CEO IV Applicant
Street ( Ui(0 .m/e. Ki-c- City y e,1vM State Wet
ZIP c(669-1- Phone oQc0 yL15 3a log'\ Cell a yL-VS 130 (0 Li
Email \*.kiw ( Yelm Business License #
EMPLOYMENT HISTORY
e« oi,` C c.i`M
Including your current employment, list the jobs you've held during the past five (5) years.
Job Title Employer City/State Fro /To
1 WkSil " - . ' cAAI 1\exi.)-e.,w aoC Mo l ca
2
3
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 �C
3 Domestic violence
4 Fraud/Identity theft X
5 Any drug-related crime
6 Any sex offense
7 Any crime against children or vulnerable adults �(
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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.
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 90.0 C Ud
Make (' Y�I o
T-UK'
Model
Color .}\\AA -e._
Plate#
State
UJINf
Owner -
Vehicle 3 Vehicle 4
Year
Make
Model
Color
Plate#
State
Owner
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SUPPLEMENTAL INFORMATION — FOR-HIRE DRIVER PERMIT APPLICANTS ONLY
YMC 05.03.030 Qualifications (self disclosure)
Qualification Yes No
1 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?
*M 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.
LSV Submit a copy of your driver's license or, if no current driver's license, your State-issued ID card.
Lr Provide an ID photo.
134 Have your fingerprints taken at YPD.
❑Submit a copy of your complete driving record (for-hire driver/operator applicants only).
M Submit your completed and signed application form.
g/Pay your fees (cash, check or debit card).
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`F r
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 hol occupa ional per 't issued under YMC 5.03, and I hereby consent to such checks.
Signature 1/(Cm i 4— Date 1 a— CO "
IV-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 9 i ti hi i Reviewed By /1/1 Review Date (-/ lii 11—)
4pproved ❑Denied Reason: ❑Incomplete application ❑Criminal record
❑Prior permit revocation ❑False information
❑05.03.060 ❑Other (specify)
LFees paid: Permit# ❑Base fee refunded: Date
HPermit ID completed ❑Applicant notified By Date
❑Permit fee only (non-fingerprint renewal)
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