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Kelly Foster -new 1.5.21 renewed#2 1.3.22 City of ye lm OCCUPATIONAL PERMIT APPLICATION Permits issued by the City of Yelm are valid in Yelm, Olympia, Turn water, and Lacey. ❑New Permit Renewal (Permit# 2 \ ' ifg< 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) IJ For-Hire Driver ❑Locksmith ❑Solicitor APPLICANT INFORMATION *Full Legal Name: (F/M/L) 1�>e Other Name(s) Used: (If additional space is needed, use the back of this page) (F/M/L) (F/M/L) / Sex W 3 !*Date of Birth 2$f f A6 *Age 1:5t SS# *Height to5,r *Weight 32-1 *Hair Color Tj1 *Eye Color Place of Birth W1304,/\171/3 t U l2 Have you ever had an occupational permit suspended or revoked? ❑Yes [PIC If, "yes,"when and where HOME ADDRESS (Do not use a P.O. Box for your street address,please)2 *Street , A- S Zf �- `City Otle.Xtklelcx. Statl�e *ZIP g.$51 *Phone 25-5-- -)004Cell 2 66-! —c0tl` *Mailing address(❑same )C) c2)-1 C AV'1 U c *email LANtJV1Ae 'kte- t_ < <dY--+ int @ -ALAkr43 '' Page 6 of 9 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 2 3 4 5 BUSINESS INFORMATION (tthee business that is related to this permit) *Business Name K.,e'VA, v Business Owner/CEO C �Tfj — ❑ Applicant Street 222-- E `? v i .6, City QArV) State ZIPQ Phone 3(CC -)ciA —L 2 Cell EmailOainia(4- kkAL1 )CchYelm Business License# EMPLOYMENT HISTORY Including your current employment, list the jobs you've held during the past five (5) years. Job Title f Employer City/State From/To 2 1 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 NNo 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 Page 7of9 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 8 of 9 • 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)? "6-VrA Are you 18 years old? 2 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 1/. 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 �I 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? *ell 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. ❑ Submit a copy of your driver's license or, if no current driver's license, your State-issued ID card. ❑ Provide an ID photo. ❑ 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. ❑ Pay your fees(cash, check or debit card). Page 9 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 11.1.4..r....01 /1111.111111..iDate) 5 J —2-1 ❑ 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 deproved ❑Denied Reason: ❑Incomplete application ❑Criminal record 0 Prior permit revocation 0 False information 005.03.060 ❑Other (specify) ❑Fees paid: Permit# ❑Base fee refunded: Date ermit ID completed pplicant notified By Date I \ bjt.5-n ❑Permit fee only (non-fingerprint renewal) Page 10 of ACCPRE) CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/29/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Deshonda Shubin NAME: Humble&Davenport Insurance Brokers Inc. (AHCNE Ext): (425)226-8221 {n/c,No): (425)255-9342 3500 Maple ValleyHwyE-MAIL DeshondaS@humbledavenport.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Renton WA 98058 INSURER A: New York Marine&General Ins Co 16608 INSURED INSURER B: Kelly Ray Foster,DBA:Kelly Kab INSURER C: PO Box 1214 INSURER D: INSURER E: Yelm WA 98597 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2062926587 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INS() WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ _ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO LOC PRODUCTS-COMP/OPAGG $ PRO- JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ 100,000 A OWNED x SCHEDULED AU2020TLP04101 07/03/2020 07/03/2021 BODILY INJURY(Per accident) $ 300,000 AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ 25,000 AUTOS ONLY _ AUTOS ONLY (Per accident) Underinsured motorist BI $ 100/300 UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) 2003 Mercury Sable 1MEFM58U63A631514 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Washington Department of Licensing For Hire Program ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 9039 AUTHORIZED REPRESENTATIVE Olympia WA 98507-9039 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD dtWASHINGTON STATE DEPARTMENT Of LICENSING Registration Certificate Model Year Make Model Body Style Vehicle identification number(VIN) Scale Weight 2003 MERC SABLE Wagon 1MEFM58U63A631514 3,514 Plate/Tag no Tab/Decal no Primary vehicle use type j 's' r'{ ' BQD0023 D045916 Passenger Vehicle 07/28/2020Issuedate 07/1Exp7/2021 Plate/Tag no Tab/Decal No Vehicle use type Issue date Exp date Gross Weight Gr wt start date Gross weight exp date Fleet no Equip no Registered Owner Legal Owner FOSTER, KELLY RAY DUSSETSCHLEGER, TIMOTHY W PO BOX 1214 22416 VALE CT SE YELM WA 98597-1214 YELM WA 98597-9086 (Brands/Comments: 21690/2003, Display tab on back license plate only-front plate is still required Anyone who knowingly makes a false statement may be guilty of a felony under state law and upon conviction shall be punished by a fine, imprisonment, or both. I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct and, as owner or authorized agent of the vehicle, it is free of any claim of lien, mortgage, conditional sale or other security interest of any person except the person or persons set forth as legal owners. X X Signature of registered owner Signature of registered owner Date and place signed Date and place signed L0107518819 TD-42Q=502TrrfVEM,Erage f oT2 Vehicle Information: BQD0023 1MEFM58U63A631514 2003 MERC SABLE Wagon Filing Registration Filing $4.50 Registration License Plate Technology $0.25 Dept.of Licensing Service $0.50 Vehicle Weight $25.00 Registration License $30.00 Service Registration Service Fee $8.00 Fee Total: $68.25 Issue Date: 07/28/2020 You can get a copy of this cash/fee receipt detail at www.dol.wa.gov. Skip a trip—go online www.dol.wa.gov • CflWASHINGTON STATE DEPARTMENT OF Driving Record - FOSTEKR313D8 CERTIFIED i LICENSING Abstract of Driving Record-Insurance This information is current as of 1/3/2021 9:39 PM Driver Information Address Information License and ID Details DLN: FOSTEKR313D8 Address on file Personal Driver License: Last: FOSTER Status: Licensed First: KELLY Issue: 12/08/2017 Middle: RAY Expire:03/28/2023 Suffix: Original issue: 07/12/1994 DOB:03/28/1969 Gender: M Restrictions Endorsements Description Lic type Code Description Code Corrective Corrective Lenses PDL B No endorsements Reinstatements Requirement No requirements DLN History DLN Start End FOSTEKR313D8 03/19/2002 Tickets Description: F04-Seat belt not used Finding date:03/08/2018 Statute:46.61.688 CMV: No Violation date: 12/08/2017 Finding: Guilty Electronic ticket: No Hazmat: No Violation#: 7Z1273265 Court name: Thurston County Fatality: No District Court No test: Exempt veh: No Mental health: No 16 Passenger: No Pass under 16: No Amended ACD: No II 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. 1 of 1 OCCUPATIONAL PERMIT MASTER APPLICATION PACKET For the following Occupations: For-Hire Driver (Taxi) Locksmith Solicitor YMC Chapter 5.03 Ordinance No. 953 Effective January 25, 2012 Occupational Permits issued by the City of Yelm are valid in Yelm, Olympia, Tumwater and Lacey. st Revised July 1, 2019 OccupationalPermits(YMC 5.03) APPLICATIONINSTRUCTIONS NewApplications Youmustsubmitaewapplicationif anyofthefollowingapplytoyou: 1) Youare applyingforanoccupationalpermitfor thefirsttime;or 2) Youhadapermitinprevious years butdidnothaveonelastyear;or 3) Youhadapermitlastyear butit was suspendedduringtheyear. Ifyouare requiredtosubmitanewapplicationheckthePermbox,and completealltheinformation requested ontheapplication form. IfyoucheckedSolicitor or For Hire Driver in thepermittype,besuretocompletethe appropriate Supplemental Informationsection. GetyourfingerprintstakenbyYelmPD withPicture ID required.This mustbe completedbefore yourapplicationwill beprocessed. These fingerprints will be used to check the criminal history files of the FBI. You have the capability to review and challenge the criminal history files located through the FBI which were used to determine your fitness for a permit YelmPD does fingerprintingfrom9:00amthrough11:00amand1:00pmthrough3:00 pmdependingonstaffavailability,TuesdaythroughThursday.Noappointmentis necessary. Proofof$10.00paymentmustaccompany service. Driver forHire,applicantsmustsubmitacopyoftheircompletedrivingrecord.This record maybeobtainedfromtheDepartmentofLicensingandwill requirethepayment ofafeeattheapplicanexpense.This requirementappliesonlyto For Hirevehicle driver/operator permitapplicants.Bringyourapplicationmaterials totheCityBusiness Licenseservicecounter toturnthemin;youcanpayyour permitfeebycheck,cashor moneyorder attheservicecounter. Ifyousubmityour applicationmaterials bymail, encloseacheck ormoneyorderfor theamountofthepermitfeeandanyother applicablefees.Makechecks ormoneyorders payabletotheCityofYelm. Permitfees.Thecurrentinitialfeefor theOccupationalPermitis $78.00per year and anyportionthereof.($10.00Permitfee;$58.00WSP/FBIrecordcheckfee;$10.00for 2 fingerprintcards), plusaseparate$35.00CityofYelmBusiness LicenseApplicationto dobusiness inYelm). Ifyoupaybycheck,beaware thatyourpermitwill notbereleasedtoyouuntil your check clears. Permit Renewal Youare eligibletorenew your permit ifallofthefollowingapplytoyou: Page 2of9 1) You have a permit issued by the City last year for the same occupation that youre applying for this year; and Page 3 of 9 2) Your permitwas notrevokedor suspendedduringtheyear. Ifyouareeligibletosubmitarenewal applicationheck thenewaboxonthe applicationform,enteryour permit numberfromlastyear,andcompleteall information ontheapplication formmarked withastar(*). Youmust also completeanyotherinformation requested on theapplication formthat has changedsinceyou submitted your prior application. Renewal applicantsmustbefingerprintedandprovideaphotographeveryfourthyear. Fingerprintingandprovidingapicture mustbecompletedbefore your applicationwill be processed. YelmPD does fingerprintingfrom9:00AMthrough11:00AMand1:00PMthrough 3:00PMdependingonstaffavailability,Tuesday throughThursday.Noappointmentis necessary. Fingerprintingcostsare$10.00. For-hiredriver/operator renewal applicantsmustsubmitacopyoftheircompletedriving record.This recordmaybeobtainedfromtheDepartmentofLicensingandwill require thepaymentofafee atthe applicanexpense.This requirementappliesonlytofor- hirevehicledriver/operator permitapplicants. Thecurrentannualfeefor newOccupationalPermits is$78.00per year or anyportion thereof.The feefor renewal permits is$30.00inayear whenyouare notrequiredtobe fingerprinted,and$78.00inayear whenyouare requiredtobefingerprinted. Bringyour applicationmaterials totheCityBusinessLicenseservicecounterfor review andpayment.Youcanpayyour fees bycheck,cashor moneyorder attheservice counter. Makechecksor moneyorders payabletotheCityofYelm.Ifyoupaybycheck, beaware thatyour permit will notbereleasedtoyouuntil your check clears. ReviewandIssuanceProcess ThePoliceDepartmentwill review your applicationmaterials anddetermineifyouare eligiblefortheOccupationPermitfor whichyouhaveapplied.Normally,thatprocess takesaboutten(10) workingdays,butitmaytakelonger, dependingonwhentheCity receives criminal recorddatafrom theWashingtonStatePatrol. Youwill becontactedwhenadecisionhas beenmadeonyour permit.Ifyouare approved,youmustcometothe Yelm Public Safety Building at 206 McKenzie Street inpersontopickupyour permit card.Toassure thatpermit cardsare actually receivedbythepersontowhomtheyare issued,we check thephotoonthepermitwiththepersonpickingupthecard atthetimewerelease thecard.For your protection,wedonotmailoutpermitcardsor releasethemtothird parties. Ifyouaredenied,youwill benotifiedbyYelmPD withthereason(s)for the denialandtheprocessyoumayusetoappeal thedecision,ifapplicable. Ifyour permitis deniedfor anyreason,youwill berefundedthepermitfee.The backgroundcheckandfingerprintingfeesarenon-refundable. Page 4of9 Youmayrequestacopyofthecriminalhistoryrecord check datathatwas usedin determiningyourfitness for apermitbycheckingtheboxintheERTIFICATIO sectionoftheapplicationatthetimeyousubmit theapplication.Ifyourequestthisdata, youwillreceiveacopy atthetimeyoupick upyour permit.Ifyourpermit is deniedand yourequestedacopyofyour criminalhistorydata,youwill needtopick upyour copyin personatthePoliceDepartmentwithinten(10) workingdays ofthetimeyoureceive your denial notice.TheCitydestroys this dataafteradecisionhasbeenmadetoissue or denyapermit,so,unlessyourequestacopyatthetimeyousubmit your application, wewill notbeabletoprovideyouwithacopyofyour criminalhistorydata. Things toKnowAboutYour Permit Permitsare goodfor thecalendar year ofissueonly. Itis your responsibilitytogeta newpermit eachyear. Noreminders or renewalnoticesare sentout. Youcanapplyfor renewalanytimeafter October 1.Planaheadtogetyour permitrenewedwellbefore thestart ofeachnewyear. There is nograceperiodforrenewing anewpermit.Currentyear permits expireat midnightonDecember31,andyoucannotlawfullyengageinapermittedoccupation after thattimeuntil youhaveyourrenewedpermit inhand. Permitfeesarefor thecalendar year ofissue(or anypart thereof).Fees arenot prorated. Renewal stickers mustbeaffixedtothepermitcard intheproper locationinorder tobe valid. Occupationalpermits arenotbusiness licenses. Itis your responsibilityeither tohave anappropriate,validbusiness licenseyourself,ifrequired,or tobeworkingunder a validbusiness licenseissuedtoyour employer. Someoccupational permits havespecific rules andregulationspertainingtohowand whentheycanbeused. Itis your responsibilitytobefamiliar withtherules and regulations thatapplytoyour permittype. \[seeYMC Chapter 5.03\] www.yelmwa.gov or requestacopy. Occupationalpermitsmaybesuspended(i.e.,takenawaytemporarily)or revoked(i.e., takenawaypermanently). Itis your responsibilitytomakesure youknowtheconditions thatcanleadtothoseactions.\[seeYMC Chapter5.03.060\] Occupationalpermits issuedbytheCityofYelmarevalidinYelmas well as Olympia, Tumwater, andLacey. Finally,misuseofOccupationalPermitscanresult inciviland/or criminal liability. Be sure tofollowtherules,regulationsandrequirementsintheYelmMunicipal Code. \[see YMC Chapter 5.03.300\] Page 5of9 City of Yelm OCCUPATIONALPERMITAPPLICATION PermitsissuedbytheCityofYelmare validinYelm,Olympia,Tumwater,andLacey. NewPermitRenewal (Permit#) Iherebyrequestapermittoworkinthefollowingbusiness, tradeoroccupation in accordancewithall lawsand/orordinancesgoverning suchbusiness,tradeoroccupationinthe CityofYelm.(YMC5.03) 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. *PERMITTYPE(Checkone)For-HireDriverLocksmithSolicitor APPLICANTINFORMATION *Full Legal Name: Kelly R Foster (F/M/L) OtherName(s)Used:(Ifadditionalspaceisneeded,usethebackofthispage) (F/M/L) (F/M/L) M 03/28/1969 52 543-88-7172 Sex*DateofBirth_*AgeSS#_ 6'5 329 Brn/Grey Brown *Height*Weight_*HairColor*EyeColor Lebanon Oregon Place ofBirth_ Haveyoueverhad anoccupational permit suspended or revoked? YesNo If,ywhen and where HOMEADDRESS(DonotuseaP.O.Boxforyourstreetaddress,please) 35611 SR 507 McKenna WA *Street*City*State 98558 253-719-2004 *ZIP_*Phone_Cell PO Box 1214 Yelm WA 98597 *Mailingaddress(same Yelmrealtor@gmail.com *email Page6of9 OTHERRECENTRESIDENCES Listall otherstatesandcitieswhereyou have lived in thepastfive(5)years. FromTo StateCity (month/year)(month/year) 1 2 3 4 5 BUSINESSINFORMATION(thebusinessthatisrelatedtothispermit) KellyKab *BusinessName BusinessOwner/CEOApplicant Kelly R Foster Yelm WA 222 Yelm Ave E StreetCityState_ 98597 360-791-1925 360-791-1925 ZIP_PhoneCell owner@kellykab.com EmailYelmBusinessLicense # EMPLOYMENTHISTORY Including yourcurrentemployment,list thejobsyouve held duringthepast five(5)years. JobTitleEmployerCity/StateFrom/To 1 Owner KellyKab Yelm, WA 2010 - Present 2 3 4 5 *CRIMINAL HISTORY(Self-disclosure) Inthe pastfive(5)years,haveyou been convictedofanyofthefollowingoffenses? Offense TypeYesNo X 1Anyfelony X 2Larceny/theft/vehicle prowling 3Domesticviolence X 4 Fraud/Identitytheft X 5 Anydrug-relatedcrime X X 6Anysexoffense X 7Anycrimeagainstchildren orvulnerable adults Page7of9 Ifyou areapplyingforaSolicitosPermitoraFor-HireDrivs Permit, Complete the appropriateSupplemental Informationsection thatfollows. Foranyothertype ofpermit, skiptotheApplicationDocumentChecklistsection. SUPPLEMENTALINFORMATIONSOLICITORPERMIT APPLICANTS ONLY YMC 05.03.200Qualifications 1.Brieflydescribe theproductsor servicesforwhichyouwill be soliciting. TAXI SERVICES 2.Please listallvehiclesyouwill beusinginyourbusiness. (Usethebackofthisformforadditionalvehicles,if necessary) Vehicle1Vehicle2 Year 2007 Make Ford Model Taurus Color Silver Plate# BZL3927 State WA Owner Kelly R Foster Vehicle3Vehicle4 Year Make Model Color Plate# State Owner Page8of9 SUPPLEMENTALINFORMATIONFOR-HIREDRIVERPERMIT APPLICANTS ONLY YMC 05.03.030Qualifications(selfdisclosure) QualificationYesNo Haveyou had avalid Drivicenseforthe pasttwoyears? 1 Ifyes,inwhatstate(s)? 1a WA Areyou 18 yearsold? 2 3 Doyou have anyphysical ormentalinfirmitiesthat mayaffectyourdriving? X Haveyou been convicted ofthree(3)ormoremovingviolations duringanyone 4 X (1)year period inthepastfive(5)years? Inthe pastfive(5)years, haveyou been convictedofoperating amotorvehicle 5 while undertheinfluenceofalcohol ordrugs? Inthe pastfive(5)years, haveyou been convictedofhavingphysical control of 6 amotorvehiclewhile undertheinfluenceofalcohol ordrugs? Inthe pastfive(5)years, haveyou been convictedofnegligentdrivingor 7 reckless operationofamotorvehicle? Inthe pastfive(5)years, haveyou been convictedofvehicularhomicideor 8 assaultwith amotorvehicle? *Allapplicantsmustcompletethissection APPLICATIONDOCUMENTCHECKLIST Youneedtodothefollowingthingsbeforeyourapplicationwillbeprocessed.Usethischecklistto makesureyou have allthematerialsyou need. Submitacopyofyourdrivicenseor, ifnocurrentdrivicense,yourState-issuedIDcard. ProvideanID photo. HaveyourfingerprintstakenatYPD. Submitacopyofyourcompletedrivingrecord(for-hiredriver/operatorapplicantsonly). Submityourcompletedand signedapplicationform. Payyourfees(cash, checkordebit card). Page9of9 CERTIFICATION Underpenalty ofperjury,Iswearthatallinformationcontainedinthisapplicationistrue,accurate and completetothebestofmyknowledgeandbelief.IalsoherebyauthorizetheCityofYelmtoconduct any reasonableinquiries,includingexaminationofmy criminalhistory,necessarytoverifythe informationI haveprovidedanddeterminemyfitnessfor thepermitforwhichIhaveapplied. I understandthatthe Citymay,atitsexpense,conductadditionalcriminal historycheckson meatanytimewhile Ihold an occupational permitissuedunderYMC 5.03,andIherebyconsentto such checks. Kelly R Foster 01-05-2022 Signature_ Date_ Irequest acopyofthecriminal historydatausedto determinemyfitnessforapermit. Cityuseonlybelowthisline ------------------------------------------------------------------------------------------------------------------------ DateReceived ReviewedBy ReviewDate Approved Denied Reason: Incompleteapplication Criminalrecord PriorpermitrevocationFalse information 05.03.060Other(specify) Feespaid: Permit#Basefeerefunded: Date PermitID completed Applicantnotified ByDate Permitfeeonly(non-fingerprintrenewal) Page10of