Private Investigator and/or Security Guard Qualifying Agent Application

Size: px
Start display at page:

Download "Private Investigator and/or Security Guard Qualifying Agent Application"

Transcription

1 Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT Kara Shangraw Licensing Board Specialist (802) kara.shangraw@sec.state.vt.us 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) kara.shangraw@sec.state.vt.us 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) kara.shangraw@sec.state.vt.us 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

4

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) kara.shangraw@sec.state.vt.us 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) kara.shangraw@sec.state.vt.us 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) kara.shangraw@sec.state.vt.us 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) kara.shangraw@sec.state.vt.us 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:

A. LICENSE BY EDUCATION

A. LICENSE BY EDUCATION Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT 05620-3402 Aprille Morrison (802) 828-2373 www.vtprofessionals.org Aprille.Morrison@sec.state.vt.us

More information

Vermont Board of Nursing INSTRUCTION TO APPLICANTS

Vermont Board of Nursing INSTRUCTION TO APPLICANTS Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing Foreign_nurse@sec.state.vt.us www.vtprofessionals.org INSTRUCTION TO APPLICANTS NCLEX RETAKE (International) Applicant

More information

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing (802) 828-2396 www.vtprofessionals.org INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE NCLEX RETAKE (Domestic)

More information

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A LICENSED NURSING ASSISTANT

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A LICENSED NURSING ASSISTANT Vermont Secretary of State Office of Professional Regulation 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing (802) 828-3089 www.vtprofessionals.org Vermont Board of Nursing INSTRUCTION TO APPLICANTS

More information

INSTRUCTION TO APPLICANTS A. ADMINISTRATOR IN TRAINING PROGRAM:

INSTRUCTION TO APPLICANTS A. ADMINISTRATOR IN TRAINING PROGRAM: Vermont Secretary of State Office of Professional Regulation 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing Home Administrators INSTRUCTION TO APPLICANTS A. ADMINISTRATOR IN TRAINING PROGRAM:

More information

APPLICATION NATUROPATHIC PHYSICIAN INSTRUCTION TO APPLICANTS

APPLICATION NATUROPATHIC PHYSICIAN INSTRUCTION TO APPLICANTS Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 APPLYING BY EXAMINATION APPLICATION NATUROPATHIC PHYSICIAN INSTRUCTION TO APPLICANTS Naturopathic Physician Aprille Morrison

More information

Applicants for Licensure as a Marriage and Family Therapist. Steps for Applicants Applying by Examination:

Applicants for Licensure as a Marriage and Family Therapist. Steps for Applicants Applying by Examination: Applicants for Licensure as a Marriage and Family Therapist Steps for Applicants Applying by Examination: 1. Complete application, pages 1, 2, 3 and 4. 2. Have every state in which you now hold or have

More information

NATUROPATHIC PHYSICIAN APPLICATION FOR NATUROPATH PHYSICAN LICENSURE INSTRUCTION TO APPLICANTS

NATUROPATHIC PHYSICIAN APPLICATION FOR NATUROPATH PHYSICAN LICENSURE INSTRUCTION TO APPLICANTS Vermont Secretary of State Office of Professional Regulation 89 Main Street, 3 rd Floor Montpelier VT 05620-3402 Aprille Morrison (802) 828-2373 www.vtprofessionals.org aprille.morrison@sec.state.vt.us

More information

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE Vermont Secretary of State Office of Professional Regulation 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing Foreign_nurse@sec.state.vt.us www.vtprofessionals.org Vermont Board of Nursing INSTRUCTION

More information

Registered Nurse Renewal Application

Registered Nurse Renewal Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Current Expiration 03/31/2013 You Must Complete The Information Below:

More information

Secretary of State Office of Professional Regulation BOARD OF PHARMACY 89 Main Street, 3 rd Floor Montpelier, VT

Secretary of State Office of Professional Regulation BOARD OF PHARMACY 89 Main Street, 3 rd Floor Montpelier, VT Secretary of State Office of Professional Regulation BOARD OF PHARMACY 89 Main Street, 3 rd Floor Montpelier, VT 05620-3402 www.vtprofessionals.org Attention: Aprille Morrison, Licensing Board Specialist

More information

Registered Nurse Renewal/Reinstatement Application

Registered Nurse Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Board of Nursing (802) 828-2396 www.vtprofessionals.org Current Expiration

More information

Licensed Nursing Assistant Renewal/Reinstatement Application

Licensed Nursing Assistant Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Licensed Nursing Assistant Renewal/Reinstatement Application Board of Nursing

More information

Optometry Renewal Application

Optometry Renewal Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Optometry Renewal Application Board of Optometry Renewal Clerk (802) 828-1505

More information

Optometry Renewal/Reinstatement Application

Optometry Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Board of Optometry 802-828-1505 renewalclerk@sec.state.vt.us www.vtprofessionals.org

More information

Applicants for Licensure as a Clinical Mental Health Counselor

Applicants for Licensure as a Clinical Mental Health Counselor Steps for Applying by Examination: Applicants for Licensure as a Clinical Mental Health Counselor 1. Submit the completed application and the $125 non-refundable application fee, payable to the Vermont

More information

Licensed Midwife Renewal/Reinstatement Application

Licensed Midwife Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Licensed Midwife Renewal/Reinstatement Application Renewal Clerk (802)

More information

This is a Legal Document. By completing and signing this you certify under

This is a Legal Document. By completing and signing this you certify under APPLICATION FOR WYOMING LICENSED PRACTICAL NURSE (LPN) LICENSURE BY ENDORSEMENT *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this you certify

More information

This is a Legal Document. By completing and signing this, you certify under

This is a Legal Document. By completing and signing this, you certify under APPLICATION FOR WYOMING REGISTERED NURSE LICENSURE with ADVANCE PRACTICE RECOGNITION (APRN) *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this,

More information

This is a Legal Document. By completing and signing, this you certify under

This is a Legal Document. By completing and signing, this you certify under APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION BY ENDORSEMENT, DEEMING, or RECERTIFICATION All certificates expire December 31 of every EVEN year This is a Legal Document. By completing and signing,

More information

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE

Vermont Board of Nursing INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE Vermont Secretary of State 89 Main St., 3 rd Floor Montpelier VT 05620-3402 Nursing (802) 828-2396 www.vtprofessionals.org INSTRUCTION TO APPLICANTS FOR LICENSURE AS A REGISTERED NURSE RE-ENTRY Applicant

More information

APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION (CNA) *All licenses expire December 31 of every EVEN year*

APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION (CNA) *All licenses expire December 31 of every EVEN year* APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION (CNA) *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this document, you certify, under

More information

APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION (CNA) *All licenses expire December 31 of every EVEN year*

APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION (CNA) *All licenses expire December 31 of every EVEN year* APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION (CNA) *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this document, you certify, under

More information

APPLICATION CHECKLIST IMPORTANT

APPLICATION CHECKLIST IMPORTANT State of Florida Department of Business and Professional Regulation Division of Professions: Talent Agencies Application for Change of Owner or Operator Form # DBPR TA-2 APPLICATION CHECKLIST IMPORTANT

More information

APPLICATION FOR WYOMING LICENSED REGISTERED NURSE with ADVANCE PRACTICE RECOGNITION *All licenses expire December 31 of every EVEN year*

APPLICATION FOR WYOMING LICENSED REGISTERED NURSE with ADVANCE PRACTICE RECOGNITION *All licenses expire December 31 of every EVEN year* APPLICATION FOR WYOMING LICENSED REGISTERED NURSE with ADVANCE PRACTICE RECOGNITION *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this document,

More information

1. NAME Last First Middle 2. TITLE (e.g., M.D., LMFT) 3. SOCIAL SECUTIRY NO. 4. PERMANENT ADRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY

1. NAME Last First Middle 2. TITLE (e.g., M.D., LMFT) 3. SOCIAL SECUTIRY NO. 4. PERMANENT ADRESS STREET CITY STATE/COUNTRY ZIP CODE COUNTY Application for Certified Family Therapist USA and Canadian marriage and family therapy license holders. This application is specifically for licensed marriage and family therapist in the United States

More information

APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION (CNA) *All licenses expire December 31 of every EVEN year*

APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION (CNA) *All licenses expire December 31 of every EVEN year* APPLICATION FOR WYOMING NURSING ASSISTANT CERTIFICATION (CNA) *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this, you certify under penalty of

More information

APPLICATION FOR WYOMING ADVANCE PRACTICE REGISTERED NURSE LICENSE *All licenses expire December 31 of every EVEN year*

APPLICATION FOR WYOMING ADVANCE PRACTICE REGISTERED NURSE LICENSE *All licenses expire December 31 of every EVEN year* APPLICATION FOR WYOMING ADVANCE PRACTICE REGISTERED NURSE LICENSE *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this document, you certify under

More information

APPLICATION FOR WYOMING ADVANCE PRACTICE REGISTERED NURSE LICENSE *All licenses expire December 31 of every EVEN year*

APPLICATION FOR WYOMING ADVANCE PRACTICE REGISTERED NURSE LICENSE *All licenses expire December 31 of every EVEN year* APPLICATION FOR WYOMING ADVANCE PRACTICE REGISTERED NURSE LICENSE *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this document, you certify under

More information

MAINE STATE BOARD OF NURSING

MAINE STATE BOARD OF NURSING MAINE STATE BOARD OF NURSING 158 STATE HOUSE STATION 161 CAPITOL STREET AUGUSTA, MAINE 04333-0158 (207) 287-1138 APPLICATION FOR LICENSE AS A CERTIFIED REGISTERED NURSE ANESTHETIST Application Received

More information

MAINE STATE BOARD OF NURSING

MAINE STATE BOARD OF NURSING MAINE STATE BOARD OF NURSING 158 STATE HOUSE STATION 161 CAPITOL STREET AUGUSTA, MAINE 04333-0158 (207) 287-1138 APPLICATION FOR LICENSE AS A CERTIFIED NURSE-MIDWIFE Application Received Fee: CC Cash Check

More information

APPLICATION FOR WYOMING LICENSED REGISTERED NURSE (RN) *All licenses expire December 31 of every EVEN year*

APPLICATION FOR WYOMING LICENSED REGISTERED NURSE (RN) *All licenses expire December 31 of every EVEN year* APPLICATION FOR WYOMING LICENSED REGISTERED NURSE (RN) *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this document, you certify under penalty

More information

LIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( )

LIBERTY DENTAL PLAN. Provider Credentialing Application. (* Required Fields) *OFFICE PHONE #: ( ) EMERGENCY PHONE #: ( ) *FAX #: ( ) (Complete one application per Provider) (* Required Fields) Credentialing Information: Owner: Associate: *PROVIDER NAME: DDS DMD Other (specify) *DATE OF BIRTH: / / Gender: Male Female Owning Dentist Name:

More information

CRIMINAL BACKGROUND CHECK by Division of Criminal Investigation (DCI)

CRIMINAL BACKGROUND CHECK by Division of Criminal Investigation (DCI) *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this document, you certify, under penalty of perjury and subject to the provisions of Wyo. Stat.

More information

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing.

APPLICATION CHECKLIST IMPORTANT Submit all items on the checklist below with your application to ensure faster processing. 1 of 11 State of Florida Department of Business and Professional Regulation Building Code Administrators and Inspectors Board Application for Authorization to Take the Principles and Practice Examination

More information

MAINE STATE BOARD OF NURSING

MAINE STATE BOARD OF NURSING MAINE STATE BOARD OF NURSING 158 STATE HOUSE STATION 161 CAPITOL STREET AUGUSTA, MAINE 04333-0158 (207) 287-1138 APPLICATION FOR LICENSE AS A REGISTERED PROFESSIONAL NURSE BY ENDORSEMENT DO NOT WRITE IN

More information

FIREARMS TRAINING COURSE REQUIREMENTS TO OBTAIN A FIREARMS QUALIFICATION CARD

FIREARMS TRAINING COURSE REQUIREMENTS TO OBTAIN A FIREARMS QUALIFICATION CARD FIREARMS TRAINING COURSE REQUIREMENTS TO OBTAIN A FIREARMS QUALIFICATION CARD The California Private Security Industry is governed by laws enacted by the California Legislature and contained in the California

More information

ATTENTION! For detailed instructions on submitting your fingerprints for a CHRC, please read and follow the attached instructions.

ATTENTION! For detailed instructions on submitting your fingerprints for a CHRC, please read and follow the attached instructions. ATTENTION! Criminal History Record Checks (CHRC) are required for all applicants. The Board may not reinstate or issue a new license to any applicant, physician or allied health practitioner, if the Board

More information

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA):

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA): Florida Certified Nursing Assistant Examination Application *APPCNAFL* Instructions: Please go to www.prometric.com/nurseaide/fl to print the current version of this application and all other forms. DO

More information

You may hold only ONE multistate license, issued from the state where you reside.

You may hold only ONE multistate license, issued from the state where you reside. APPLICATION FOR WYOMING LICENSED REGISTERED NURSE (RN) *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this document, you certify, under penalty

More information

SUPERVISION REPORT INSTRUCTIONS Licensed Alcohol and Drug Abuse Counselor

SUPERVISION REPORT INSTRUCTIONS Licensed Alcohol and Drug Abuse Counselor Vermont Secretary of State Montpelier VT 05620-3402 (802) 828-2390 diane.lafaille@sec.state.vt.us www.vtprofessionals.org SUPERVISION REPORT INSTRUCTIONS Licensed Alcohol and Drug Abuse Counselor PLEASE

More information

INSTRUCTIONS FOR COMPLETION OF ADVANCED PRACTICE APPLICATION

INSTRUCTIONS FOR COMPLETION OF ADVANCED PRACTICE APPLICATION KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS 66612-1230 (785) 296-4929 INSTRUCTIONS FOR COMPLETION OF ADVANCED PRACTICE APPLICATION Licensure in Kansas

More information

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training State of Florida Department of Health Board of Osteopathic Medicine Application for Registration as an Osteopathic Physician in Training Board of Osteopathic Medicine 4052 Bald Cypress Way, #C-06 Tallahassee,

More information

MULTISTATE LICENSE APPLICATION

MULTISTATE LICENSE APPLICATION MULTISTATE LICENSE APPLICATION for LICENSED REGISTERED NURSE or LICENSED PRACTICAL/VOCATIONAL NURSE with an active Wyoming license This is a Legal Document. By completing and signing this document, you

More information

APPLICATION FOR NATUROPATHIC DOCTOR

APPLICATION FOR NATUROPATHIC DOCTOR APPLICATION FOR NATUROPATHIC DOCTOR Completion of this application form is necessary for consideration for licensure. Disclosure of this information is voluntary; however, failure to disclose all requested

More information

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA):

If applying for Testing Accommodations under the Americans with Disabilities Act (ADA): Florida Certified Nursing Assistant Examination Application *APPCNAFL* Instructions: Please go to www.prometric.com/nurseaide/fl to print the current version of this application and all other forms. DO

More information

NORTH CAROLINA MARRIAGE AND FAMILY THERAPY LICENSURE BOARD

NORTH CAROLINA MARRIAGE AND FAMILY THERAPY LICENSURE BOARD NORTH CAROLINA MARRIAGE AND FAMILY THERAPY LICENSURE BOARD Mailing Address: Post Office Box 5549, Cary, NC 27512 Phone: (919) 469-8081 Fax: (919) 336-5156 Email: ncmftlb@nc.rr.com Web: www.nclmft.org APPLICATION

More information

INSTRUCTIONS FOR REINSTATEMENT, REACTIVATION AND RESUMPTION OF PRACTICE APPLICATION OF A NEW JERSEY LICENSE

INSTRUCTIONS FOR REINSTATEMENT, REACTIVATION AND RESUMPTION OF PRACTICE APPLICATION OF A NEW JERSEY LICENSE Division of Consum er Affairs State Board of Professional Engineers and Land Surveyors rd 124 Halsey Street, 3 Floor, Newark, NJ 07102 www.njconsumeraffairs.gov (973) 504-6460 INSTRUCTIONS FOR REINSTATEMENT,

More information

**NON-SWORN PERSONNEL**

**NON-SWORN PERSONNEL** Benson Police Department City of Benson **NON-SWORN PERSONNEL** To: Applicants Applicants are advised that a drug test will be given, and a Polygraph examination may be given as a part of the total application/background

More information

APPLICATION FOR RECIPROCAL LICENSE NURSING HOME ADMINISTRATOR

APPLICATION FOR RECIPROCAL LICENSE NURSING HOME ADMINISTRATOR APPLICATION FOR RECIPROCAL LICENSE NURSING HOME ADMINISTRATOR WEST VIRGINIA NURSING HOME ADMINISTRATORS LICENSING BOARD P. O. BOX 522 WINFIELD, WV 25213 Physical Address: 13049 Winfield Rd. Winfield, WV

More information

CITY OF SLAYTON Application for Police Service APPENDIX A

CITY OF SLAYTON Application for Police Service APPENDIX A CITY OF SLAYTON Application for Police Service APPENDIX A Directions: 1. PRINT clearly and give complete and accurate information. If you do not, you may be removed from further consideration. USE BLACK

More information

WI Procedures for Applying for Examination (Work Experience Instructor Candidate)

WI Procedures for Applying for Examination (Work Experience Instructor Candidate) W WI Procedures for Applying for Examination (Work Experience Instructor Candidate) The following information will assist you with the necessary procedures for applying for your examination: DEPARTMENT

More information

Pennsylvania State Board of Barber Examiners

Pennsylvania State Board of Barber Examiners This application is for Applicants that have an existing license that has been expired for five (5) years or more. Pennsylvania State Board of Barber Examiners REINSTATEMENT APPLICATION FOR PROFESSIONAL

More information

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training

State of Florida Department of Health. Board of Osteopathic Medicine. Application for Registration as an Osteopathic Physician in Training State of Florida Department of Health Board of Osteopathic Medicine Application for Registration as an Osteopathic Physician in Training Board of Osteopathic Medicine 4052 Bald Cypress Way, #C-06 Tallahassee,

More information

COMMISSIONED SECURITY OFFICER APPLICATION

COMMISSIONED SECURITY OFFICER APPLICATION COMMISSIONED SECURITY OFFICER APPLICATION FOR OFFICE USE ONLY EFFECTIVE 12-2016 EXPIRES PROCESSED BY NOTICE: Information contained on this application is considered a public record and may be released

More information

LIBERTY DENTAL PLAN. Dental Hygienist - Credentialing Application. City: State: DEGREE: City: State: DEGREE:

LIBERTY DENTAL PLAN. Dental Hygienist - Credentialing Application. City: State: DEGREE: City: State: DEGREE: *Required Fields LIBERTY DENTAL PLAN Dental Hygienist - Credentialing Application Please complete one application per Dental Hygienist Demographic Information: Male Female *HYGIENIST NAME: RDH Other *DATE

More information

APPLICATION FOR REINSTATEMENT OF AN EDUCATOR S LICENSE (PRINT OR TYPE ALL INFORMATION)

APPLICATION FOR REINSTATEMENT OF AN EDUCATOR S LICENSE (PRINT OR TYPE ALL INFORMATION) FORM 1R REINSTATEMENT MISSISSIPPI DEPARTMENT OF EDUCATION Office of Educator Licensure P. O. Box 771 Jackson, MS 39205-0771 TELEPHONE (601) 359-3483 OFFICE USE ONLY Application Complete / / APPLICATION

More information

License Requirements in addition to requirements outlined below (Documentation must be provided):

License Requirements in addition to requirements outlined below (Documentation must be provided): APPLICATION FOR WYOMING FOREIGN EDUCATED LICENSED PRACTICAL NURSE/REGISTERED NURSE (LPN/RN) *All licenses expire December 31 of every EVEN year* This is a Legal Document. By completing and signing this

More information

OREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application)

OREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application) OREGON PRACTITIONER CREDENTIALING APPLICATION (Not an Employment Application) Prior to completing this credentialing application, please read and observe the following: Healthcare Organizations may contract

More information

Please print clearly as you fill out the application. Social Security #: Are you known by other names while previously employed?

Please print clearly as you fill out the application. Social Security #: Are you known by other names while previously employed? San Xavier District Tohono O'odham Nation Please print clearly as you fill out the application. Human Resources Office Only Date Received: Title of Position Desired: How did you learn about this vacancy:

More information

Employee Registration Information

Employee Registration Information Employee Registration Information The licensee (employer) must submit the application on behalf of every employee hired to work as a private detective or armed security guard, even if the employee has

More information

SPEECH-LANGUAGE PATHOLOGY ASSISTANT (SLPA) REQUIREMENTS AND INSTRUCTIONS

SPEECH-LANGUAGE PATHOLOGY ASSISTANT (SLPA) REQUIREMENTS AND INSTRUCTIONS South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Examiners in Speech-Language Pathology and Audiology 110 Centerview Dr. Columbia SC 29210 P.O. Box 11329 Columbia SC

More information

MARYLAND BOARD OF PHYSICIANS P.O. Box 2571 Baltimore, Maryland

MARYLAND BOARD OF PHYSICIANS P.O. Box 2571 Baltimore, Maryland MARYLAND BOARD OF PHYSICIANS P.O. Box 2571 Baltimore, Maryland 21215 www.mbp.state.md.us E-mail: mdh.mbppadispense@maryland.gov : ADDENDUM FOR PHYSICIAN ASSISTANT (PA) TO DISPENSE PRESCRIPTION DRUGS INSTRUCTIONS

More information

Professional Credential Services, Inc.

Professional Credential Services, Inc. Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Licensure Application for Athletic Trainers For the Massachusetts Board of Allied Health Professionals If

More information

REVISED 05/12 STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA

REVISED 05/12 STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA Email st-socialwork@pa.gov STATE BOARD OF SOCIAL WORKERS, MARRIAGE AND FAMILY THERAPISTS AND PROFESSIONAL COUNSELORS P.O. BOX 2649 HARRISBURG, PA 17105-2649 APPLICATION FOR A LICENSE BY EXAMINATION TO

More information

ATTENTION! For detailed instructions on submitting your fingerprints for a CHRC, please read and follow the attached instructions.

ATTENTION! For detailed instructions on submitting your fingerprints for a CHRC, please read and follow the attached instructions. ATTENTION! Criminal History Record Checks (CHRC) are required for all applicants. The Board may not reinstate or issue a new license to any applicant, physician or allied health practitioner, if the Board

More information

KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS (785)

KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS (785) KANSAS STATE BOARD OF NURSING Landon State Office Building 900 SW Jackson, Ste 1051 Topeka, KS 66612-1230 (785) 296-4929 INSTRUCTIONS FOR COMPLETION OF RENEWAL APPLICATION Online Renewal is available!!!

More information

New Jersey Motor Vehicle Commission

New Jersey Motor Vehicle Commission Instructor License Type & Number New Jersey REMEDIAL DRIVER EDUCATION PROGRAM INITIAL INSTRUCTOR LICENSE APPLICATION Official Use Only P.O. Box 170 Trenton, New Jersey 08666-0170 (609) 292-6500 ext.5094

More information

DIVISION OF PROFESSIONAL LICENSURE BOARD OF CERTIFICATION OF OPERATORS OF DRINKING WATER SUPPLY FACILITIES

DIVISION OF PROFESSIONAL LICENSURE BOARD OF CERTIFICATION OF OPERATORS OF DRINKING WATER SUPPLY FACILITIES The Commonwealth of Massachusetts DIVISION OF PROFESSIONAL LICENSURE BOARD OF CERTIFICATION OF OPERATORS OF DRINKING WATER SUPPLY FACILITIES 1000 Washington Street, Suite 710 Boston, Massachusetts 02118

More information

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Subsurface Sewage Disposal System INSTALLER License Application

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Subsurface Sewage Disposal System INSTALLER License Application STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH Subsurface Sewage Disposal System INSTALLER License Application General Policies and Procedures IMPORTANT: THE DEPARTMENT WILL NOT REVIEW HAND-DELIVERED

More information

Professional Credential Services, Inc.

Professional Credential Services, Inc. Professional Credential Services, Inc. P.O. Box 198689 - Nashville, TN 37219-8689 www.pcshq.com Licensure Application for Occupational Therapists For the Massachusetts Board of Allied Health Professionals

More information

Instructions and Application for Speech Language Pathologist Method 3, Meet all requirements for certifications(s) but do not have certification

Instructions and Application for Speech Language Pathologist Method 3, Meet all requirements for certifications(s) but do not have certification HEALTH OCCUPATIONS PROGRAM Speech Language Pathology and Audiology P.O. Box 64882, St. Paul, Minnesota 55164-0882 Telephone: (651) 201-3726 Fax: (651) 201-3839 Email: health.slpa@state.mn.us Instructions

More information

LICENSURE BY RECIPROCITY INFORMATION AND INSTRUCTIONS FOR REGISTERED NURSES EDUCATED AND LICENSED IN CANADA

LICENSURE BY RECIPROCITY INFORMATION AND INSTRUCTIONS FOR REGISTERED NURSES EDUCATED AND LICENSED IN CANADA The Commonwealth of Massachusetts LICENSURE BY RECIPROCITY INFORMATION AND INSTRUCTIONS FOR REGISTERED NURSES EDUCATED AND LICENSED IN CANADA I. General licensure by reciprocity information Nurse Licensure

More information

Instructions and Application for Speech Language Pathologist

Instructions and Application for Speech Language Pathologist HEALTH OCCUPATIONS PROGRAM Speech Language Pathology and Audiology P.O. Box 64882, St. Paul, Minnesota 55164-0882 Telephone: (651) 201-3726 Fax: (651) 201-3839 Email: health.slpa@state.mn.us Instructions

More information

NURSING HOME ADMINISTRATOR REQUIREMENTS AND INSTRUCTIONS

NURSING HOME ADMINISTRATOR REQUIREMENTS AND INSTRUCTIONS South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Long Term Health Care Administrators 110 Centerview Dr. Columbia SC 29210 P.O. Box 11329 Columbia SC 29211-1329 Phone:

More information

NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS

NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS LIMITED VOLUNTEER DENTAL LICENSE INFORMATION PACKET This information packet includes the following: 1) A copy of the Limited Volunteer Dental License Rules

More information

CRNA INITIAL CREDENTIALING APPLICATION

CRNA INITIAL CREDENTIALING APPLICATION CRNA INITIAL CREDENTIALING APPLICATION Revised 01/12 GENERAL INSTRUCTIONS LocumTenens.com CVO must credential all providers prior to placement into any practice location. All information requested in this

More information

10111 Richmond Avenue, Suite 400, Houston, Texas (713) / (866) (Toll Free) / (713) (Fax)

10111 Richmond Avenue, Suite 400, Houston, Texas (713) / (866) (Toll Free) / (713) (Fax) Application Date: \ \ Date Available: \ \ Provider s Name: O MD O DO O PA O NP SS # : City: State: Zip: Home Phone ( ) Work Phone ( ) Pager ( ) Cell Phone ( ) E-Mail address: Driver s Lic. # Expires: \

More information

CITY OF BRANDON POLICE DEPARTMENT APPLICATION FOR EMPLOYMENT. ALL applicants MUST attach items 1, 2, 3, 4 I. PERSONAL HISTORY

CITY OF BRANDON POLICE DEPARTMENT APPLICATION FOR EMPLOYMENT. ALL applicants MUST attach items 1, 2, 3, 4 I. PERSONAL HISTORY CITY OF BRANDON POLICE DEPARTMENT APPLICATION FOR EMPLOYMENT MAIL OR DELIVER TO: THE CITY OF BRANDON 1000 MUNICIPAL DRIVE P.O. BOX 1539 BRANDON, MS 39043 ATTN: PERSONNEL Date: Notice: Application MUST

More information

Employee Statement and Security Guard Application FEE $36

Employee Statement and Security Guard Application FEE $36 FOR OFFICE USE ONLY CASH#: UID: PREV. UID: CLASS: CODE: New York State Department of State Division of Licensing Services P.O. Box 22052 Albany, NY 12201-2052 Customer Service: (518) 474-7569 www.dos.ny.gov

More information

Legislative Administration Office Only. Last First Middle Are you known by other names while previously employed? YES NO.

Legislative Administration Office Only. Last First Middle Are you known by other names while previously employed? YES NO. Tohono O odham Nation Legislative Branch P.O. Box 837 Sells, Arizona 85634 Phone: (520) 383-2470 (520) 383-5260 Fax: (520) 383-2479 Website: www.tolc-nsn.org Legislative Administration Office Only Date

More information

Name of Sex: M F Applicant: Last First Middle. Date of Birth: Social Security Number: Phone: ( ) City State Zip. Phone: ( ) City State Zip

Name of Sex: M F Applicant: Last First Middle. Date of Birth: Social Security Number: Phone: ( ) City State Zip. Phone: ( ) City State Zip SCHNEIDER REGIONAL MEDICAL CENTER 9048 SUGAR ESTATE ST. THOMAS, U.S.V.I 00802 APPLICATION FOR TEMPORARY PRIVILEGES (USED FOR URGENT PATIENT NEED AND LOCUM TENENS) COMPLETE THE APPLICATION IN FULL. PRINT

More information

APPLICATION FOR ADMINISTRATOR-IN-TRAINING NURSING HOME ADMINISTRATOR. (Please type or print; Answer all questions in full)

APPLICATION FOR ADMINISTRATOR-IN-TRAINING NURSING HOME ADMINISTRATOR. (Please type or print; Answer all questions in full) APPLICATION FOR ADMINISTRATOR-IN-TRAINING NURSING HOME ADMINISTRATOR (Please type or print; Answer all questions in full) West Virginia Nursing Home Administrators Licensing Board P. O. Box 522 Winfield,

More information

Application for Temporary Authorization Original OR Renewal (Instructional)

Application for Temporary Authorization Original OR Renewal (Instructional) FORM 38 (Revised 1/02) PART I - Received by County PART II - PERSONAL STATEMENT OF APPLICANT PLEASE TYPE OR PRINT IN INK. Application for Original OR Renewal (Instructional) WV DEPARTMENT OF EDUCATION

More information

WEST VIRGINIA BOARD OF PHYSICAL THERAPY 2 Players Club Drive, Suite 102 Charleston, West Virginia Telephone: (304) Fax: (304)

WEST VIRGINIA BOARD OF PHYSICAL THERAPY 2 Players Club Drive, Suite 102 Charleston, West Virginia Telephone: (304) Fax: (304) WEST VIRGINIA BOARD OF PHYSICAL THERAPY Charleston, West Virginia 25311 Telephone: (304) 558-0367 Fax: (304) 558-0369 REQUIREMENT CHECKLIST FOR ENDORSEMENT APPLICANTS The following is required for licensed

More information

STATE OF MAINE NURSING HOME ADMINISTRATORS LICENSING BOARD APPLICATION FOR LICENSURE. Temporary Administrator

STATE OF MAINE NURSING HOME ADMINISTRATORS LICENSING BOARD APPLICATION FOR LICENSURE. Temporary Administrator STATE OF MAINE NURSING HOME ADMINISTRATORS LICENSING BOARD APPLICATION FOR LICENSURE Temporary Administrator Department of Professional and Financial Regulation Office of Professional and Occupational

More information

(January 2017) Published by: CAL FIRE EMS Program 4501 State Highway 104 Ione, CA

(January 2017) Published by: CAL FIRE EMS Program 4501 State Highway 104 Ione, CA EMERGENCY MEDICAL TECHNICIAN INITIAL AND RE-CERTIFICATION APPLICATION PACKET (January 2017) Published by: CAL FIRE EMS Program 4501 State Highway 104 Ione, CA 95640-9705 DEPARTMENT OF FORESTRY AND FIRE

More information

Reactivation Requirements

Reactivation Requirements South Carolina Department of Labor, Licensing and Regulation South Carolina Board of Medical Examiners 110 Centerview Dr Columbia SC 29210 P.O. Box 11289 Columbia SC 29211 Phone: 803-896-4500 Medboard@llr.sc.gov

More information

UPGRADE- PRIVATE SECURITY OFFICER (PSO) TO COMMISSIONED SECURITY OFFICER (CSO) OR COMMISSIONED SCHOOL SECURITY OFFICER (CSS0)

UPGRADE- PRIVATE SECURITY OFFICER (PSO) TO COMMISSIONED SECURITY OFFICER (CSO) OR COMMISSIONED SCHOOL SECURITY OFFICER (CSS0) UPGRADE- PRIVATE SECURITY OFFICER (PSO) TO COMMISSIONED SECURITY OFFICER (CSO) OR COMMISSIONED SCHOOL SECURITY OFFICER (CSS0) FOR OFFICE USE ONLY EFFECTIVE 8-2015 EXPIRES PROCESSED BY NOTICE: Information

More information

STATE OF KANSAS OFFICE OF THE ATTORNEY GENERAL Through the KANSAS BUREAU OF INVESTIGATION INSTRUCTIONS

STATE OF KANSAS OFFICE OF THE ATTORNEY GENERAL Through the KANSAS BUREAU OF INVESTIGATION INSTRUCTIONS Please read and be familiar with: STATE OF KANSAS OFFICE OF THE ATTORNEY GENERAL Through the KANSAS BUREAU OF INVESTIGATION INSTRUCTIONS Application for Certification as Firearm Trainer Criminal use of

More information

ATTENTION! For detailed instructions on submitting your fingerprints for a CHRC, please read and follow the attached instructions.

ATTENTION! For detailed instructions on submitting your fingerprints for a CHRC, please read and follow the attached instructions. ATTENTION! Criminal History Record Checks (CHRC) are required for all applicants. The Board may not reinstate or issue a new license to any applicant, physician or allied health practitioner, if the Board

More information

Township of Lower Salford, Montgomery County 379 Main Street, Harleysville PA 19438

Township of Lower Salford, Montgomery County 379 Main Street, Harleysville PA 19438 Township of Lower Salford, Montgomery County 379 Main Street, Harleysville PA 19438 Application for Employment as a Probationary Police Officer Instructions: Before completing this form, carefully read

More information

GLYNN COUNTY SHERIFF S OFFICE IS AN EQUAL OPPORTUNITY EMPLOYER

GLYNN COUNTY SHERIFF S OFFICE IS AN EQUAL OPPORTUNITY EMPLOYER 100 Sulphur Springs Road Brunswick, GA 31520 Telephone: (912) 554-7600 Web Page Address: www.glynncountysheriff.org INSTRUCTIONS AND INFORMATION PLEASE READ CAREFULLY BEFORE BEGINNING 1. Please complete

More information

Employment Application NOTICE OF POLICY

Employment Application NOTICE OF POLICY Shayne E. Heap, Sheriff Elbert County Sheriff s Office 751 Ute Avenue, P.O. Box 486 Kiowa, Colorado 80117 Ph: 303-621-2027 Fax: 303-621-2055 www.elbertcountysheriff.com Employment Application NOTICE OF

More information

UPGRADE- PRIVATE SECURITY OFFICER (PSO) TO COMMISSIONED SECURITY OFFICER (CSO) OR COMMISSIONED SCHOOL SECURITY OFFICER (CSSO)

UPGRADE- PRIVATE SECURITY OFFICER (PSO) TO COMMISSIONED SECURITY OFFICER (CSO) OR COMMISSIONED SCHOOL SECURITY OFFICER (CSSO) UPGRADE- PRIVATE SECURITY OFFICER (PSO) TO COMMISSIONED SECURITY OFFICER (CSO) OR COMMISSIONED SCHOOL SECURITY OFFICER (CSSO) FOR OFFICE USE ONLY EFFECTIVE 12-2016 EXPIRES PROCESSED BY NOTICE: Information

More information

PUBLIC SERVICE COMMISSION FOR-HIRE DRIVER S LICENSE APPLICATION CHECKLIST

PUBLIC SERVICE COMMISSION FOR-HIRE DRIVER S LICENSE APPLICATION CHECKLIST MARYLAND PUBLIC SERVICE COMMISSION Transportation Division WILLIAM DONALD SCHAEFER TOWER 6 ST. PAUL STREET, 18 th Floor BALTIMORE, MD 21202-6806 TELEPHONE: 410-767-8128 OR 1-800-492-0474 FAX: 410-333-6088

More information

A $ application fee in the form of a money order made payable to LSBN must accompany this form.

A $ application fee in the form of a money order made payable to LSBN must accompany this form. OFFICE USE ONLY: APPROVED BY (initial) DATE PERMIT ISSUED RN LICENSE NUMBER DATE RN LICENSE ISSUED ATTACH 2 X 2 PHOTO With tape only - Attach a 2 x 2 inch passport type, fade-proof photo taken in the last

More information

Initial Application Letter of Instruction

Initial Application Letter of Instruction STATE OF NEVADA BOARD OF OCCUPATIONAL THERAPY P.O. BOX 34779 Reno, Nevada 89533-4779 (775) 746-4101 / Fax: (775) 746-4105 / Toll Free: (800) 431-2659 Email: board@nvot.org / Website: www.nvot.org TYPES

More information

New Jersey Motor Vehicle Commission

New Jersey Motor Vehicle Commission New Jersey STATE OF NEW JERSEY P.O. Box 170 Trenton, New Jersey 08666-0170 (609) 292-6500 ext. 5014 FAX# 609-292-4400 mvcblsprocessing@mvc.nj.gov Chris Christie Governor Kim Guadagno Lt. Governor Raymond

More information

Township of Lower Salford, Montgomery County 379 Main Street, Harleysville PA 19438

Township of Lower Salford, Montgomery County 379 Main Street, Harleysville PA 19438 Township of Lower Salford, Montgomery County 379 Main Street, Harleysville PA 19438 Application for Employment as a Probationary Police Officer Instructions: Before completing this form, carefully read

More information