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Ohio Qualifying Agent Application

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Ohio Qualifying Agent Application 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                                                                                            QUALIFYING AGENT APPLICATION
        Affix a 2" x 2" color photograph
        of the registrant in this space.           •     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.
Photo must be on a white background with the
registrant’s full face visible (NO headgear) and   •     Fill out all applicable sections of this application. Incomplete applications and
 the photo must be no more than 30 days old.             applications that are filled out improperly will be returned for correction.
    Copies of driver license photos are not
                    acceptable.                    •     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.
 Write the name of the registrant on the back of
  the photo and use only transparent tape to       •     A check or money order, made payable to Ohio Treasurer of State, MUST be remitted
    affix the photograph. Do not use glue or             with this application. Cash is not accepted.
                  opaque tape.


CLASS OF REGISTRATION (CHECK ONE)                            PURPOSE OF REGISTRATION (CHECK ONE)
   (A) Private Investigator & Security Guard Registration       $30.00 Initial QA application for company with Rap Back (Must be received with PSU 0006).
   (B) Private Investigator Registration                        $30.00 Replacement / Additional QA application for company with Rap Back.
   (C) Security Guard Registration Only
APPLICANT INFORMATION
FIRST NAME                                             MIDDLE NAME                  LAST NAME                                            SUFFIX

SOCIAL SECURITY NUMBER              CURRENT HOME ADDRESS (NO P.O. BOXES)                          PHONE NUMBER                 DATE OF BIRTH
                                                                                                  (    )     -
CITY                                                              STATE        ZIP CODE           COUNTY

CITY OF BIRTH                                          STATE OF BIRTH                                   COUNTRY OF BIRTH

HEIGHT              WEIGHT                 HAIR COLOR            EYE COLOR               CITIZENSHIP
                                LBS.
SCARS AND MARKS

DATE FINGERPRINTS SUBMITTED                            AUTHENTICATION NUMBER                            EMAIL ADDRESS


PREVIOUS ADDRESS (Please list residences for past ten years, if different from above. Attach additional sheets if necessary.)
PREVIOUS HOME ADDRESS                                                                             BEGINNING DATE               END DATE

CITY                                                              STATE        ZIP CODE           COUNTY


PREVIOUS HOME ADDRESS                                                                             BEGINNING DATE               END DATE

CITY                                                              STATE        ZIP CODE           COUNTY


PREVIOUS HOME ADDRESS                                                                             BEGINNING DATE               END DATE

CITY                                                              STATE        ZIP CODE           COUNTY


PREVIOUS HOME ADDRESS                                                                             BEGINNING DATE               END DATE

CITY                                                              STATE        ZIP CODE           COUNTY


PREVIOUS HOME ADDRESS                                                                             BEGINNING DATE               END DATE

CITY                                                              STATE        ZIP CODE           COUNTY



PSU 0007 4/13 [760-1299] Page 1 of 3
BACKGROUND INFORMATION
1. Have you ever had a license to practice a private investigation and security services profession denied,
   suspended or revoked, or been subject to other disciplinary action in this or any other state? (If “Yes”, attach an              Yes   No
   explanation.)
2.   Have you ever been convicted of or do you have a pending felony charge?
                                                                                                                                    Yes   No
     (If “Yes”, attach final court journal entry copies with dates and an explanation of situation.)
3.   Have you ever been adjudicated incompetent under Ohio Revised Code Section 5122.301?
     (If “Yes”, attach final court journal entry copies restoring you to legal capacity.)                                           Yes   No

4.   Do you currently, or have you ever held a commission from a law enforcement agency? (If “Yes”, attach a copy of
     your Ohio Basic Peace Officer Training Certificate.)                                                                           Yes   No

5.   Are you currently a parole officer, probation officer, bailiff, prosecuting attorney, assistant prosecuting attorney,
     correctional employee, youth services employee, firefighter, EMT, or investigator of the bureau of criminal                    Yes   No
     identification and investigation?
EMPLOYMENT INFORMATION (Please list your employment for the past seven years, starting with the company to which you are
currently applying. Attach additional sheets if necessary.)
COMPANY NAME                                                                                  START DATE                     END DATE

ADDRESS

CITY                                                           STATE        ZIP CODE          COUNTY

JOB DUTIES:


COMPANY NAME                                                                                  START DATE                     END DATE

ADDRESS

CITY                                                           STATE        ZIP CODE          COUNTY

JOB DUTIES:


COMPANY NAME                                                                                  START DATE                     END DATE

ADDRESS

CITY                                                           STATE        ZIP CODE          COUNTY

JOB DUTIES:


COMPANY NAME                                                                                  START DATE                     END DATE

ADDRESS

CITY                                                           STATE        ZIP CODE          COUNTY

JOB DUTIES:


EDUCATION: O.A.C. 4501:5-1-06(D) (Law Enforcement or Criminal Justice related field. Attach a copy of Certificate/Degree / Transcript.)
SCHOOL NAME                                                                ADDRESS

MAJOR                                             DID YOU GRADUATE?                                    DEGREE RECEIVED?
                                                      Yes         No                                     Yes         No


MILITARY POLICE EXPERIENCE: O.A.C. 4501:5-1-06(C) (Attach a copy of DD214.)
BRANCH                                            START DATE                                           END DATE




PSU 0007 4/13 [760-1299] Page 2 of 3
Are you, or have you ever been, a registered employee of a licensed private investigator or security
guard provider in Ohio?                                                                                                                      Yes         No
PROVIDER NAME                                                                                        REGISTRATION EMPLOYEE ID

PROVIDER NAME                                                                                        REGISTRATION EMPLOYEE ID

PROVIDER NAME                                                                                        REGISTRATION EMPLOYEE ID




Are you, or have you ever been, licensed as a private investigator or security guard provider in Ohio?                                       Yes         No
PROVIDER NAME                                                                                        PROVIDER LICENSE NUMBER

PROVIDER NAME                                                                                        PROVIDER LICENSE NUMBER

PROVIDER NAME                                                                                        PROVIDER LICENSE NUMBER


Are you, or have you ever been, licensed to practice in any other state? (Attach a copy of license and
Letter of Good Standing. Please attach additional sheets if necessary.)                                                                      Yes         No
PROVIDER NAME                                                   LICENSE NUMBER                           STATE ISSUED                ORIGINAL DATE ISSUED

PROVIDER NAME                                                   LICENSE NUMBER                           STATE ISSUED                ORIGINAL DATE ISSUED

PROVIDER NAME                                                   LICENSE NUMBER                           STATE ISSUED                ORIGINAL DATE ISSUED


EXPERIENCE / QUALIFICATIONS (Please attach additional sheets if necessary.)
List below any additional experience that better qualifies you to serve as a qualifying agent.




I affirm that the information within and attached hereto this application is complete and accurate. I authorize PISGS to enroll me in the retained applicant
fingerprint database (rapback). I understand that my criminal history will be continually monitored, and any new arrest will be reviewed by PISGS.
SIGNATURE OF QUALIFYING AGENT                                  PRINTED NAME OF QUALIFYING AGENT                                 DATE


X
This section must be completed by a corporate officer, partner or owner other than the applicant if the class of the company is other than Sole Proprietorship.
I have read the information provided by the applicant and have no reason to believe that it is false or misleading.
SIGNATURE                                                     PRINTED NAME


X
TITLE                                                                                                                            DATE




PSU 0007 4/13 [760-1299] Page 3 of 3

				
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