Bilingual Licensed Psychologist, Security Evaluations

Revised **/**** Page * of * PSP-**

Texas Department of Public Safety PRIVATE SECURITY PROGRAM

Regulatory Services Division

www.dps.texas.gov

ADMINISTRATION OF MINNESOTA MULTIPHASIC PERSONALITY INVENTORY For a Commissioned Security Officer or Personal Protection Officer License Private Security Applicant Information

Last Name:

First Name: Middle Initial:

Social Security Number:

Email Address:

Date of Birth: Country of Birth: State:

I am a (choose one) [ ] Licensed Psychologist, [ ] Licensed Psychiatrist and on

(date) I administered the Minnesota Multiphasic Personality Inventory of the above-named individual and have interpreted the results and have determined that the applicant is not disqualified from either of the above licenses by reason of a mental health condition. Psychologist or Psychiatrist Information

Last Name:

First Name: Middle Initial:

State and License Number:

Business Address:

City: State: Zip Code:

Email: Phone:

I verify the information provided above is true and correct, and I understand that this is an official Government record and that any false statement made on this document, or any other supplement provided to DPS may result in criminal prosecution. Administering Psychologist’s or Psychiatrist’s Signature Date: THIS DOCUMENT IS NOT PUBLIC INFORMATION AND IS VALID UNLESS WITHDRAWN OR INVALIDATED AND IS VALID ONLY IF SIGNED BY A LICENSED PSYCHOLOGIST OR PSYCHIATRIST.

This form and any attachments may be forwarded electronically to: https://www.dps.texas.gov/rsd/contact/psb.aspx

Applicant is not required to submit page 2.

KISERO

JOHNSON A

***-**-****

*********.********@*****.***

08/18/1952 KENYA

4

12/15/2025

BEAN

ANTHONY M

TX 37328

909 9TH AVE SUITE 208

FORT WORTH TEXAS 76104

***************@*****.*** 682-***-****

12/15/2025

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