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MODESTO POLICE DEPARTMENT Funeral Escort Application CASE # ALL APPLICANTS Application filled out completely. Driver's license - valid with proper endorsement (MPD will make a copy). License Fee - $58.00 - Cash, check or money order made out to "City of Modesto". Applicant must be livescanned by MPD ($32 fee for DOJ & $10 livescan fee) Proof of Liability Insurance - $500,000. The "Municipal Code Acknowledgement" must be signed in the presence of police personnel. Current C.P.R. card and Social Security Card (MPD will make a copy). Release and Waiver for background check. Proof of satisfactory completion of a traffic safety program - evidence of curriculum including instruction materials, skills taught & practiced or an instructional program of traffic safety. Proof of inspection of vehicle to be used in escort work. Inspection by Modesto Police Department. Copy of City of Modesto Business License. Hold Harmless Agreement. APPLICANT INFORMATION NAME OF BUSINESS HOME WORK HOME NAME OF EMPLOYER EMPLOYER CITY OF MODESTO BUSINESS LICENSE LIST ALL ARRESTS AND CONVICTIONS: DATE CHARGE CITY/STATE DISPOSITION List all moving traffic violations/convictions in the 5 years prior to the date of this application DATE CHARGE CITY/STATE DISPOSITION I certify under penalty of perjury that the above information is true and correct: Signature of Applicant: DATE: Application Received by: IBM# In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website at SIGN ---PAGE BREAK--- CITY OF MODESTO FLEET SERVICES FUNERAL ESCORT VEHICLE SAFETY INSPECTION Date: Operator: Vehicle Number: V.I.N.: License No: Make: Model: Mileage: INSPECTION ITEM PASS FAIL SEE NOTES Test Drive Glass/Windshield Horn Lights V.I.N. Belts/Hoses Tires Brakes Bearings Steering Suspension Shocks Frame Emergancy Kill Clutch Switch Clutch Adjust Throttle Return COMMENTS CERTIFICATION APPROVED INSPECTION PERFORMED BY: CERTIFICATION DENIED SIGNATURE: SIGN