Private Investigator and/or Security Guard Qualifying Agent Application

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1 Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT Kara Shangraw Licensing Board Specialist (802) Private Investigator and/or Security Guard Qualifying Agent Application This application applies to persons who have met the experience requirements and have successfully completed the applicable examination(s). Persons licensed may serve as the Qualifying Agent (responsible person for an agency), be a sole proprietor, or otherwise practice independently. Please note: As of July 1, 2014, all applicants will be required to have an FBI check as well as the VCIC check. You must have fingerprints taken at a Criminal Justice Center. See details below. 1. Completed Application. 2. Application Fee: $ Unarmed; ($ for Armed status). Please make your check payable to Vermont Secretary of State. Application fees are non-refundable. 3. Attach a 2 inch by 2 inch photograph of you (the applicant) where indicated. 4. Request that character references and verifications of your experience be submitted to the Board. 5. FBI and VCIC background check. As part of the application you will now be undergoing a VCIC and an FBI Check. According to the Department of Public Safety s New Applicant Procedure, an applicant must bring the FBI National Record Check Release Form and take it to a tary Public to complete. You will be required to show two forms of identification: a birth certificate, passport, driver's license or social security card. Once we receive your release form, you will receive a "Vermont Criminal Information Center Fingerprint Authorizing Certificate" and a list of Fingerprint Identification Centers. You will need to contact one of the centers to make an appointment. You must bring the certificate to the appointment and you will be required to pay the $25.00 fee to have fingerprints taken. The Office of Professional Regulation is responsible for the record check fee. You must either have the agency you are working for submit a letter (on their letterhead) stating the date, time, and location of where your fingerprints are scheduled to be taken or submit a photocopy of your receipt from the location you have had them taken (be sure it states where it was taken). 6. An applicant requesting Armed Status must have received firearms training by a Vermont licensed instructor. The Instructor must complete page eight (8). You may contact the Office for a list of Firearms Instructors who are licensed in Vermont. 7. Completed Verification of Licensure (if applicable). Applicant completes and signs top portion of form, and forwards to any licensing agency in which the applicant is currently licensed or has ever been licensed. IT IS A CRIMINAL OFFENSE IN VERMONT TO BEGIN EMPLOYMENT WITHOUT A VALID TEMPORARY OR PERMANENT REGISTRATION HAVING BEEN ISSUED BY THE BOARD OF PRIVATE INVESTIGATIVE AND SECURITY SERVICES.

2 Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT Kara Shangraw Licensing Board Specialist (802) INFORMATION REGARDING EXAMINATION Separate examinations are administered to applicants applying for licensure as a private investigator or security guard. Each examination consists of objective, multiple choice questions. The Office of Professional Regulation will make arrangements with the applicant to come to the Board Office to take the exam(s). If the applicant is applying for both a private investigator and a security guard license, the applicant must complete both exams. An applicant who fails an exam may be re-examined but may not take an examination more than twice during any twelve month period for the same license category. A licensed private investigator or security guard may serve as the responsible person for an agency (Qualifying Agent). EXAMINATION SUBJECT AREAS Private Investigative Security Guard 1. PD/Security Service licensing laws PD/Security Service licensing laws 26 V.S.A. '' V.S.A. '' V.S.A. '' V.S.A. '' Administrative Rules Administrative Rules 2. Fair Credit Reporting Act 15 U.S.C. ' Public Records In Vermont 1 V.S.A. '' PREPARATION FOR EXAMINATION Applicants taking either examination should be thoroughly familiar with the Vermont Statues and the Administrative Rules of the Board of Private Investigative and Security Services. Applicants taking the Private Investigator=s examination should be thoroughly familiar with the Fair Credit Reporting Act and Public Records in Vermont. General knowledge of the investigation and security field obtained through practical experience and academic studies is also necessary.

3 Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT Kara Shangraw Licensing Board Specialist (802) Board of Private Investigative and Security Services Licensure as a Private Investigator and/or Security Guard (Qualifying Agent) Private Investigator License Security Guard License Private Investigator and Security Guard (Use Ink or Typewritten only) First Name (Legal name no nicknames) MI Last Name & Title (Jr., Sr., II, III, etc.) Circle One: Mr. Mrs. Ms. Dr. Previous Name(s) (Maiden) Social Security Number: / / ** (Providing your social security number (SSN) is mandatory, and requested under the authority granted by 42 U.S.C. 405(c)(2)(C). It will be used by the Departments of Taxes, Child Support, and the Department of Labor in the administration of Vermont law, to identify individuals affected by such laws. Your SSN is not disclosed as part of a public records request); OR Passport Number: *** (If you do not have a social security number you must provide a passport number as evidence that there is no attempt to procure a license fraudulently (3 V.S.A. 129a) P.O. Box Mailing Address: Street/Apt # City/State/Zip Country 911 Address: (if different than mailing) P.O. Box Street/Apt # City/State/Zip Home Phone: Work Phone: ( ) - ( ) - Cell Phone: ( ) - Date of Birth Gender: (Circle One) Female Male

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5 Vermont Mandatory Good Standing Declarations CHILD SUPPORT: Child Support Orders, 15 V.S.A. 795(b): Good standing for child support is defined by 15 V.S.A. 795(d). You must check the appropriate box. As of the date of this application: I am not subject to a child support order. I am subject to a child support order and I am in good standing or in full compliance with a plan to pay any and all child support. I am subject to a child support order and I am NOT in good standing or in full compliance with a plan to pay any and all child support. Please contact the Office of Child Support at (802) OCS must report your compliance to this office before you may be issued a license. TAXES: Taxes Due to the State of Vermont, 32 V.S.A. 3113(b): Good Standing for taxes due is defined by 32 V.S.A. 3113(g). You must check the appropriate box. As of the date of this application: I am in good standing with respect to, or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. I am NOT in good standing * with respect to or in full compliance with a plan to pay any and all taxes due to the Vermont Department of Taxes. Please contact the Vermont Department of Taxes at (802) for more information. The Tax Department must report your compliance to this office before you may be issued a license. DISTRICT COURT FINES/JUDICIAL BUREAU: Court judgments for fines or penalties, 4 V.S.A. 1110(b): Good standing for court judgments is defined by 4 V.S.A. 1110(c). You must check the appropriate box. As of the date of this application: I have no unpaid judgments issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. I am NOT in good standing with respect to any unpaid judgment issued by the judicial bureau or criminal division of the superior court for fines or penalties for a violation or criminal offense. You must provide this office documentation of compliance before you may be issued a license. RESTITUTION ORDERS: Unpaid Judgments, 13 V.S.A. 7043a: Good standing for restitution orders is defined by 13 V.S.A. 7043a(c). You must check the appropriate box. As of the date of this application: I have no restitution order. I am in good standing with respect to any restitution order. I am NOT in good standing with respect to any restitution order. You must provide this office documentation of compliance before you may be issued a license.

6 Vermont Mandatory Credential and Fitness Questions Circle or for each of these questions. If the answer is, follow the instructions provided. Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) denied an application by you for a license, certificate, or registration to practice a profession or occupation? If, you must attach a copy of the order or official notification of the action(s). Has Vermont or any other state, federal authority, or other jurisdiction (US or elsewhere) taken any disciplinary action (restricted, suspended, revocation or conditioned) against a license, certificate, or registration that you hold or held in any profession or occupation? If, you must provide a copy of the order or official notification of the action. Have you ever surrendered a license, certificate or registration to a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and copies of any applicable documentation. Are you currently under investigation by a licensing authority in Vermont or any other state, federal authority or other jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and a copy of any available information from the licensing authority. Have you EVER been arrested, taken into custody, held for investigation or questioning, cited into court, charged by any law enforcement authority, completed a diversion program, had a criminal case dismissed, or been convicted of a crime other than a minor traffic violation? (te: Driving While Intoxicated and Driving Under the Influence are not minor traffic violations. ) If the answer is "," you must provide a written explanation and copies of police affidavits and court documents. Do you have any criminal charges pending against you in any jurisdiction (US or elsewhere)? If, you must provide a detailed written explanation and attach a copy of the charging documents. te: Vermont law requires that you report to the Office of Professional Regulation a felony conviction or any conviction of a crime related to the practice of your profession within 30 days. 3 V.S.A. 129a(a)(11). The answers to the following questions are not subject to public disclosure: Do you have a physical or mental condition or disorder which in any way impairs or limits your ability to practice this profession with reasonable skill and safety? If, you must have your health care provider submit a detailed statement explaining how you are able to practice safely. Does your use of alcohol, substances, or prescription medications impair or limit your ability to practice this profession with reasonable skill and safety? If, you must provide a detailed written explanation. Are you currently addicted to or in any way dependent on alcohol or habit forming drugs? If, you must provide a detailed written explanation.

7 List below every state in which you now hold, or have ever held, a license to practice. State License # Date Issued Date Expires(d) Employment: Name of Agency where you will be working Name under which the business entity will conduct business, register licensees, and advertise in Vermont. Address of Agency Agency s License Number Attach current photo of applicant. 2" x 2" PHOTO Education: List below all schools and/or colleges attended and training courses completed. Name of School or College City and State Dates Attended mm/yy to mm/yy Certificate or Degree Earned

8 Employment History - Provide a list of your work experience, in REVERSE chronological order (most recent first). If you were unemployed, in school, etc., during the past five years, please so indicate. There must be no gaps. If the space provided is insufficient attach additional sheets. Employer's Location: (city & state) Job Title: Dates Employed: From: To: Duties: Reason for Leaving: Employer's Location: (city & state) Job Title: Dates Employed: From: To: Duties: Reason for Leaving: Employer's Location: (city & state) Job Title: Dates Employed: From: To: Duties: Reason for Leaving:

9 Employment History Continued Employer's Location: (city & state) Job Title: Dates Employed: From: To: Duties: Reason for Leaving: Employer's Location: (city & state) Job Title: Dates Employed: From: To: Duties: Reason for Leaving: Employer's Location: (city & state) Job Title: Dates Employed: From: To: Duties: Reason for Leaving:

10 Military: Have you ever served in an active military organization of the United States or foreign government? If yes, complete the information below. Branch of Service Specialty Rank Held Provide period(s) of active service Type of discharge or separation If the reason for discharge is less than honorable, attach a letter of explanation. Reserves: Have you ever served as an active member of the Reserve Forces (any branch) of the United States, any foreign government, or the National Guard? If yes, complete the information below. Branch of Service Specialty Rank Held Provide period(s) of active service Type of discharge or separation If the reason for discharge is less than honorable, attach a letter of explanation. Statement of Applicant I certify, under the pains and penalties of perjury, that all information I have provided in this application is true and accurate. I understand that furnishing false information may constitute unprofessional conduct and result in the denial of my application or further disciplinary action. The maximum penalty for perjury is fifteen years in prison and/or a $10,000 fine. (13 V.S.A. 2901) Signature of Applicant Date

11 Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT Kara Shangraw Licensing Board Specialist (802) Character Reference and/or Verification of Experience Applicant s The above named applicant has submitted an application for licensure as a private investigator or security guard or both, to either work independently, for an agency, or to serve as the qualifying agent of an agency. The applicant has given your name as a reference. Reference providers must be over 18 years of age, cannot be related to the applicant, and must personally know the applicant for a period of at least five years. To qualify for licensure, the applicant must demonstrate at least two years of experience (2,000 hours in the three year period immediately preceding the date of application). Applicants for a combination Private Investigative and Security Guard license shall submit documentation showing two years experience (4,000 hours in the three year period immediately preceding the date of application). The Board of Private Investigative and Security Services appreciates your assistance in the evaluation of this applicant to practice as a private investigator and/or security guard in the State of Vermont. The Board attaches considerable importance to the character reference and verification of experience in its evaluation of applicants for licensure and asks you to give us a good sense of the applicant s experience, performance and character as well as the specific nature of the work performed. Please refer to Section 2.3 of the Board s Administrative Rules which may be found via our Web site at Please return completed questionnaire(s) directly to the Vermont Board of Private Investigative and Security Services. The Board seeks the period of employment, the position he or she held, a description of the work or services rendered, level of responsibility, etc. Please also describe reason for termination of employment if applicable.

12 Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT Kara Shangraw Licensing Board Specialist (802) To be completed by the Applicant s Character Reference or the person verifying the Applicant s work experience Character Reference Person Verifying Work Experience Please print or type: Applicant s Applicant s Address: List below Your Last List below Your First Middle: Former if applicable: Address: State: Phone: Address: City: Zip: Fax: Business Information: Firm Address: City;State;Zip: Phone: Fax: How long have you known the applicant?. of Years. of Hours I know of my own knowledge that the applicant has been employed for a period of not less than hours in the previous three years as a/an: years or Investigator or Security Guard Police officer with an organized police department of the State, county or municipality thereof With an investigative agency or security services agency of the United States of America or any state, county or municipality thereof. Other: Do you believe the applicant to be of good character and integrity and recommend that the license applied for be issued?

13 Please state any additional comments below (or on a separate sheet of paper). Describe in detail the work or services rendered: Reason for termination of employment: I certify under the pains and penalty of perjury that the above statements are true and accurate to the best of my knowledge, and that they are not made for the purpose of aiding an unqualified applicant to become licensed, but with full realization of the responsibility toward the public where the safeguarding of life, health and property is concerned or involved. Signature Date: Your Present Position And Title:

14 Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT VERIFICATION OF GOOD STANDING Kara Shangraw Licensing Board Specialist (802) APPLICANT: Complete the applicant section of this form and forward to every state in which you now hold or have ever held a license to practice. Please print. Address: City, State, Zip: Date of Birth: License. Social Security Number: Date Issued: I hereby authorize the Private Investigative and Security Guard Licensing Authority in the State of ( ) to furnish to the Vermont Office of Professional Regulation the information requested below. Applicant s Signature: Date: STATE LICENSING AUTHORITY: Please complete this section and return to the address above: The above-named individual was issued License Number Date: to practice as a (check below) on: Security Guard Private Investigator Dog Handler Basis of Registration or Licensure Status of Registration and/or License Examination What Year? Endorsement/ Reciprocity From What State? Waiver Other, Specify Status: Active Inactive Lapsed Date Expires/d: Disciplinary Action: Has this license ever been revoked, suspended, limited, surrendered, restricted, placed on probation, encumbered in any way or is it currently under investigation? If, please attach a copy of the decision or final disposition. Signature: State: Title: Date:

15 Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT Kara Shangraw Licensing Board Specialist (802) VERIFICATION OF FIREARMS STATUS TRAINING CERTIFICATION or RE-CERTIFICATION FORM Firearms certification or re-certification must be taught by a Vermont licensed instructor (See 26 V.S.A. 3175a). Name of Applicant: (Last, First, Middle) Name of Employing Agency (At time of Firearms Certification) Employing Agency s License Number Date of Applicant Employment Name of Firearms Training Organization Address of Firearms Training Organization Date(s) Applicant Attended Firearms Training Guard Dog Handler (16 Hours) Firearms Qualification Only (16 Hours) Firearms Re-Certification Specify the type of weapon(s) that the applicant is qualified to instruct: Comments: Print Name of Instructor Instructor s Vermont License. And Expiration date Signature of Instructor : Date:

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