Department of Emergency Services and Public Protection AGENCY USE ONLY: Date Received

Division of State Police

Special Licensing and Firearms Unit

Employees: Failure to provide complete and accurate information will result in denial.

Employers: Incomplete applications will be returned. All applications must be legible.

APPLICATION FOR REGISTRATION OF SECURITY OFFICER

OR PRIVATE INVESTIGATOR

Applicant/Employer Information

Application for registration of employee for: Security Officer Private Investigator

1. Agency Name Contemporary Services Corporation Date 10.7.2023

2. Agency Address 460 Smith Street Suite B2 Middletown, CT 06457

Street City State Zip

3. Agency Phone 860-***-**** Agency License Number

4. On 7 of October, 2023 I informed the applicant of C.G.S. §§ 29-156a (PI) or 29-161q (SO).

(Day/Month/Year)

Signature of Licensee or Designee

Evan Paradis, Branch Manager

Print Name/Title

SO Identification Card #

Employee Information

5. Name Date of Birth

LAST FIRST MIDDLE

6. Resident Address Telephone Street City State Zip

7. Birthplace Race: Sex: Hgt: Wgt.:

City State

8. U. S. Citizen Yes No Alien Reg. No. If Naturalized, Where Date

This information is only required if registration is as a Private Investigator.

9. Describe your experience in the position applied for. If you need additional space,

check here and use additional paper.

10. Previous employment for at least the past five years - include occupation, names, and contact information of employers. If you need additional space, check here and use additional paper.

OCCUPATION

EMPLOYER

ADDRESS

DATES EMPLOYED

TELEPHONE

11. Have you ever been convicted in any court of any crime? Yes No

If yes, list all convictions, including charges, location, date of arrest and disposition. Also, list all pending charges, including nolles within the past 13 months. If you need additional space, check here and use additional paper.

DATE

CHARGE/VIOLATION

LOCATION (Town/State)

DISPOSTION (Fine/time served/probation)

12. Are you vested with police powers? Yes No

I subscribe and affirm under penalties of false statement, that the statements made in this application have been examined by me and to the best of my knowledge and belief are true and correct. I also understand that false statements are punishable in Connecticut pursuant to C.G.S. Section 53a-175b (Class A Misdemeanor) and/or as prescribed in accordance with C.G.S. §§ 29-161, 29-161g, q, x, y, and z inclusive as amended by PA 08-73 with fines up to $5000 or imprisonment up to one year or both.

STATE OF Signature of Employee

SS

Date of Oath

COUNTY OF

APPEARED:

Notary Public, Justice of Peace, Pursuant to C.G.S. 1-24

Commissioner of the Superior Court

ADDRESS: My Commission Expires:

Subscribed and sworn to before me this day of, 20

FOR AGENCY USE ONLY

This application is: Approved / Denied Date:

Reviewed by:

Signature Badge Number Print Name/Title/Badge Number

BASIS FOR DENIAL:

Criminal Record (Felony) Non-conforming/Unclear Photographs

Criminal Record (Misdemeanor) Fingerprint Cards Rejected by S.P.B.I.

Incomplete/Incorrect Information on Fingerprint Cards Other:

Incomplete/Incorrect Information on Application: Item Number(s):

INCLUDE 2X2 PHOTO

WITH AND WITHOUT

HEAD COVER

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