◆ SpookStack

Sutomabite fileage Rate Class. ean 8 6 ame . _—— : ATO: 2S List Principat Operator first, ~ Real. to [Use of Ayto Agpheant; b | coe thame Cen wn 7 . ftatudext Teslding 8 at school, give name of schoal: PRINCIPAL OPERATOR sftesa than Z yrs. give prior . | addrasses for full 2 yrs. : Oi Own . | Dome. - * _D trae, ' &YRent . HAnt. - --O Other 25. Typecf . Res.= Oriver Train. Oo Yes Ovo . tf within 2 yrs..: -Pormer Emp. (s) |, st es: . =i: Applicant and ae EG COND Otner Crivers ci) es; an a 2 Reina 4 urea! “By or on. behalf “of,” porson’ , taspe.’ siliin Scr the aceldent of have judg tmagntcsmist such perear, ans 3 Ruthacceit: struck in, reat ond and operator’: cad Sead oi at weed in the i + Linurrenarks. ° Hy and’ frequently: use. &@ Nnor-owncd- tote? MISES OF aecupation? i. “yes.” non: ots NO-. ve Lenployer’s Na may : Fane hy i's Wags leasure f " 1h 7 Schone. Ohe ‘iz ts Mork, 3tar hore Maer then other operators In househotd. Oriver’s License No. oy tf under 25 & single, reside with parents? oe Location of Acc. State} . ; 4 Damaged hy “hit-and-run” driver and acc. ‘. dent reported to police withly 24 hours from: ; ° ae . time of eccident * $ Other person Involved fn accident wes ¢on-. victed. Operator was not cenvicted. « entero = O Yes. © No. Sapte Sees oo nee. tompa t Ovigiie. d : ti tualieis — (Peemamerclat —~ ty] 11 Tart of Sergo) gre Way tt Park, nr. of £5. of Teens, “amet. | Pa “ttle. Dharm on fags f map Ey a toe ° ta tn mi. Famaie - 2 7. . Os Fara Br. Feaais 4 Femata Fama: “Tat Kea. fa metsegesding Ctass: Merit Marital bicansed | Status “and miles one way. Cc dren’ s Male: Sirthdates n Household (Mo,-0 treet Ad dareae OF —_ Physical if impairment 6 aoa injury confined to occupa ; -mobila.:No liability payments rE Tass... vat heal magical payments. * "7 Operating a vehicte of a typo ne) . ‘rating under the pian. * Does applicant row fav © Yes O No If Yas,’ Expiration - Tae 46.9. caso lee " specified. en FONE 7" O,YEs - wea et ” ¥ith respect ty the applicant and ale “A Has any ticonse er permit tordsive entnanetetindtiiarabetemenaat mbers of his heuss ny motor vebiclz ben yoked, sucponded or rufusad? .& Has any intarare cracotled or refusod of ivan nutes th “213. :- : etl int ede fee tssret or reluce Gisy Citehar finnish ea rea umaterdr cf sny Mb iets ticetin the > pectetar ou at “ws ro, ‘of the invite once te dt ters sudsatbstioe of clon: 2°" eT ile quest fate in “Yoshinsptues, $3.4.