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WESLEY SNOW - EXP 12/2018 City of yeCm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yelm are valid in Yelm, Olympia, Tumwater, and Lacey. ❑New Permit C 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 IRLocksmith ❑Solicitor APPLICANT INFORMATION *Full Legal Name: (F/M/L) Qcq'.`k U, ,,J 6\3 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 -P'‘y1\ *Age (O SS# - \ S\L\ *Height V `\ \ 2)'. 0 *Hair Color (q `� *Eye Color S3QOW j) Place of Birth ACO tc\ r\ \ I S\.\ . Have you ever had an occupational permit suspended or revoked? ❑Yes .,e0 If, "yes," when and where HOME ADDRESS (Do not use a P.O. Box for your street address, please) *Street \yW\ I 1\O 9S).3a *City t.C‘ji\ *State *ZIP cq,:50\1 *Phone •0"15-et"\•\."(e7ct0Cell gyp_ '#V - fyltc' *Mailing address (❑same c', . ZOy3 �(S-\...)4 •Vim. °k9;S9 *email S a0 t\M \c‘Al '10-0 (=Ata) 604)M ` Page 5 of 9 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 Make Model Color Plate# State Owner Vehicle 3 Vehicle 4 Year Make Model Color Plate# State Owner Page 7 of 9 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 Date ❑ 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 Reviewed By Review Date ❑Approved ❑Denied Reason: El Incomplete application CI Criminal record ❑Prior permit revocation ❑False information ❑05.03.060 ❑Other (specify) El Fees paid: Permit # ❑Base fee refunded: Date ❑Permit ID completed ❑Applicant notified By Date ❑Permit fee only (non-fingerprint renewal) Page 9 of 9 A SUPPLEMENTAL INFORMATION —FOR-HIRE DRIVER PERMIT APPLICANTS ONLY YMC 05.03.030 Qualifications (self disclosure) Qualification IIIHave you had a valid Driver's License for the past two years? Yes No 1a - ■■ 2 Are you 18 years old? 3 Do ou have an •h sical or mental infirmities that mr ■■ 4 Have you been convicted of three (3) or more moving violations duriing any one 1 ear •eriod in the •ast five 5 ears? In the past five (5) years, have you been convicted of operating ■■ © while under the influence a motor vehicle of alcohol or dru.s? ■■ 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 dru•s? ■■ In the past five (5) years, have you been convicted of negligent driving or reckless o•eration of a motor vehicle? ■ 8 In the past five (5) years, have you been convicted of vehicul ■ assault with a motor vehicle? ar homicide or *M applicants must complete this section APPLICATION DOCUMENT CHECKLIST You need to do the following things before your application will be processed. Use this the make sure you have all the materials you need. cklist to ❑ Submit a copy of your driver's license or, if no current driver's license, your State-issued ❑ Provide an ID photo. ID card. ❑ Have your fingerprints taken at YPD. ❑ Submit a copy of your complete driving record (for-hire driver/operator applicants only). ❑ Submit your completed and signed application form. Y) ❑ Pay your fees (cash, check or debit card). Page 8 of 9 OTHER RECENT RESIDE List all other NOES . er states and l si cities wher ■ e you have lived in the past five (5) Yea © rs. v m (month/Froear To Milmonth/ ear BUSINESS INFOlielwilialeRMATION (the business that is rel ted to IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII *Business Name this permit) Business Owner/CEO IL + _ Street L\ZIP ► City State0 Applicant Phone , �A ' Email • Cell Yelm Business EMP�QYMENT HISTORY License # M Including your current employment, list the jobs you've held during theast five p (5) years. Job Title Emplo er 1 From/To .1111112 3 a ORy (Se 5� co ;ted of any of the following offenses? \01 NP�N� e y°ub�� S wi /a Yes No ,I51�2a� ' nge II kkl\V V ,to0y ,F �\ Jr WO w e rZ -sults \� \0 r �c �( page P ,f ,(Jt t,' :0 % g) 'tt S ' $ (6' \I 0 , De9 e rag „, S I,