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Ohio Security Guard Provider License

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Ohio Security Guard Provider License Powered By Docstoc
					                                           OHIO DEPARTMENT OF PUBLIC SAFETY
                                     PRIVATE INVESTIGATOR SECURITY GUARD SERVICES
                                                   1970 West Broad Street
                                                      P.O. Box 182001
                                                 Columbus, OH 43218-2001
                                          PHONE (614) 466-4130 FAX (614) 466-0342
                                                     www.pisgs.ohio.gov


PISGS                                                                                               PROVIDER APPLICATION

•   This form is interactive: you may type your responses directly onto the form before printing. Otherwise, this form must be
    typewritten or printed legibly in black ink.
•   Fill out all applicable sections of this application. Incomplete applications and applications that are filled out improperly will be
    returned for correction.
•   This form is to be completed in compliance with Ohio Revised Code (R.C.) 4749 and Ohio Administrative Code (O.A.C.) 4501:5-1.
•   A check or money order for $375 for the main office, plus $100 for all branch offices, made payable to Ohio Treasurer of State,
    MUST be remitted with this application. Cash is NOT accepted.
•   At least one Qualifying Agent Application form (PSU 0007) must accompany this application.

                             BUSINESS TYPE (Check One)                                          CLASS OF LICENSE (Check One)
       CORPORATION                                       PARTNERSHIP                                  (A) - PRIVATE INVESTIGATOR/
       $375.00                                           $375.00                                          SECURITY GUARD

       LIMITED LIABILITY CORPORATION                     SOLE PROPRIETORSHIP                          (B) - PRIVATE INVESTIGATOR
       $375.00                                           $375.00
                                                                                                      (C) - SECURITY GUARD

                                                      COMPANY INFORMATION
INTENDED COMPANY NAME

INTENDED TRADE NAME/D.B.A. NAME (Optional)

PHYSICAL ADDRESS (No P.O. Boxes)

CITY                                                  STATE                  ZIP CODE                  COUNTY

DAYTIME PHONE NUMBER                         FAX NUMBER                                     EMAIL ADDRESS
(      )    -                                (    )      -
MAILING ADDRESS (Optional)

CITY                                                  STATE                  ZIP CODE                  COUNTY

ADDRESS TO DISPLAY TO THE PUBLIC?                            PHYSICAL             MAILING
                                                      APPLICANT INFORMATION
FIRST NAME                                   LAST NAME                                      TITLE

DAYTIME PHONE NUMBER                                                    EMAIL ADDRESS
(      )    -
                                                         QUALIFYING AGENT
LIST AT LEAST ONE OFFICER, PARTNER, OR EMPLOYEE WHO WILL SATISFY THE REQUIREMENT OF R.C. 4749.03 (A)(1) FOR THE
COMPANY. EACH QUALIFYING AGENT MUST COMPLETE A QUALIFYING AGENT APPLICATION (PSU 0007) AND SUBMIT IT WITH THIS
APPLICATION.
FIRST NAME                              MIDDLE NAME                           LAST NAME               SUFFIX

SOCIAL SECURITY NUMBER                                                  CURRENT LICENSE NUMBER (If applicable)



FIRST NAME                                   MIDDLE NAME                                     LAST NAME              SUFFIX

SOCIAL SECURITY NUMBER                                                  CURRENT LICENSE NUMBER (If applicable)




PSU 0006 1/13 Page 1 of 2
                                                               BRANCH OFFICE
PHYSICAL ADDRESS (No P.O. Boxes) (Attach additional pages if necessary.)

CITY                                                    STATE               ZIP CODE                     COUNTY

DAYTIME PHONE NUMBER                          FAX NUMBER                                     EMAIL ADDRESS
(      )   -                                  (     )      -
MAILING ADDRESS (Optional)

CITY                                                    STATE               ZIP CODE                     COUNTY

ADDRESS TO DISPLAY TO THE PUBLIC?                              PHYSICAL            MAILING
                                                                CERTIFICATION
HAS THIS COMPANY, OR ANY COMPANY YOU OR ANY OFFICER HAVE BEEN AFFILIATED WITH, EVER HAD A LICENSE TO PRACTICE A
REGULATED PROFESSION DENIED, SUSPENDED, REVOKED, OR BEEN SUBJECT TO OTHER DISCIPLINARY ACTION IN THIS OR ANY
OTHER STATE?
    YES (If yes, attach explanation.)
    NO

I affirm that the information provided within, and attached hereto, this application is complete and accurate.

APPLICANT’S SIGNATURE                             APPLICANT’S PRINTED NAME                     DATE


X




PSU 0006 1/13 Page 2 of 2

				
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