Security Guard Private Investigator

OHIO DEPARTMENT OF PUBLIC SAFETY

PRIVATE INVESTIGATOR SECURITY GUARD SERVICES

**** **** ***** ******

P.O. Box 182001

Columbus, Ohio 43218-2001

PHONE 614-***-**** FAX 614-***-****

www.pisgs.ohio.gov

PISGS EMPLOYEE REGISTRATION APPLICATION

CLASS OF REGISTRATION (CHECK ONE)

Private Investigator & Security Guard Registration (A) Private Investigator Registration (B)

Security Guard Registration (C)

EMPLOYEE REGISTRATION INFORMATION

FIRST NAME: M.I.: LAST NAME: SUFFIX: SSN: DATE OF BIRTH: PHONE NUMBER: HOME ADDRESS: CITY: STATE: ZIP CODE: COUNTY: CITY OF BIRTH: STATE OF BIRTH: COUNTRY OF BIRTH: HEIGHT: WEIGHT: HAIR COLOR: EYE COLOR: HIRE DATE: SCARS AND MARKS: DATE FINGERPRINTS SUBMITTED: AUTHENTICATION #: NAME CHANGE REQUESTS Complete former name information if applying for a name change. Include a copy of the new Social Security Card. FORMER FIRST NAME: FORMER MIDDLE NAME: FORMER LAST NAME: VETERAN INFORMATION (OPTIONAL)

Are you or your spouse a veteran or active member of the United States Armed Forces? YES NO If yes, attach a copy of you or your spouse’s DD214 or current military I.D. for verification purposes. PUBLIC RECORD AVAILABILITY (Ohio Revised Code [R.C] 149.43) Are you currently a commissioned peace officer, prosecuting or assisting prosecuting attorney, correctional employee, youth services employee, firefighter, EMT, probation officer, bailiff,or an investigator of the bureau of criminal identification and investigation? YES NO CERTIFICATION

Have you been convicted of a felony within the past three years? YES NO Have you been convicted of a misdemeanor within the past twelve months? YES NO By signing this document, I attest that all of the information I provided is true and accurate to the best of my knowledge. I understand that if I knowingly make a false statement on this application I may be subject to criminal prosecution, and potential disciplinary action, including denial, suspension, or rejection of my registration. I authorize PISGS to enroll me in the retained applicant fingerprint database and, as a result, I understand PISGS will continually monitor my criminal history for any new arrest information. PRINT NAME OF EMPLOYEE: SIGNATURE: DATE: I have read the information provided by the applicant and have no reason to believe that it is false or misleading. PRINT NAME OF QUALIFYING AGENT: SIGNATURE OF QUALIFYING AGENT : DATE: