Form Dopl Ap 069 – Fill Out and Use This PDF

State of Utah

DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING

160 East 300 South, P.O. Box 146741-Salt Lake City, Utah 84114-6741

Telephone (801) 530-6628

www.dopl.utah.gov

SECURITY PERSONNEL:

ARMORED CAR SECURITY OFFICER

***Please list your full legal name as it appears on your driver’s license, Social Security Card, etc.***

Last Name:	First Name:		Middle Name:
Social Security Number:		Maiden Name:
I certify under penalty of perjury that:

I am a citizen of the United States and I have a valid US Driver License or US State ID.

License/State ID Number: ________________

State: ________

I am a citizen of the United States currently living outside the United States and do not have a valid US Drivers License or US State ID. Attach a legible copy of your valid passport or other documentation to verify you are a legal citizen of the United States.

I am a non-citizen of the United States, who is lawfully present in the United States. I have a valid US Drivers License or US State ID. License/State ID Number: ________________ State: ________

I am a non-citizen of the United States, who is lawfully present in the United States and I do not have a valid US Drivers License or US State ID. Attach a legible copy of your current and valid government issued document showing evidence of authorization to work in the United States.

I am a foreign national not physically present in the United States.

Mailing Address:

City:			State:	ZIP:
 Male	Phone #:	E-Mail:
Date of Birth:

Female

List all other licenses, registrations, or certifications issued by any state which you now hold or have ever held in any profession. (Use additional sheets if necessary.)

Profession:

License Number:	Issue Date:

Profession:

AFFIDAVIT and RELEASE AUTHORIZATION

1.I certify under penalty of perjury that I am a United States citizen or a qualified alien who is lawfully able to work in the United States.

2.I certify that I have read and understand all statutes and rules pertaining to my practice as an Armored Car Agent in Utah and I agree to comply with such.

3.I certify that am qualified in all respects for the license for which I am applying in this application.

4.I certify that to the best of my knowledge, the information contained in the application and its supporting document(s) is free of fraud, forgery, misrepresentation, omission of material fact; is truthful, correct, and complete; discloses all material facts regarding the applicant; and that I will update or correct the application as necessary, prior to any action on my application.

5.I authorize all persons, institutions, organization, schools, governmental agencies, employers, references, or any others not specifically included in the preceding characterization, which are set forth directly or by reference in this application, to release to the Division of Occupational and Professional Licensing, State of Utah, any files, records, or information of any type reasonably required for the Division of Occupational and Professional Licensing to properly evaluate my qualifications for licensure/certification/registration by the State of Utah.

Signature of Applicant: ________________________________________________ Date of Signature: ___ /___ /______ (mm-dd-yyyy)

DO NOT WRITE IN THIS SECTION - FOR DIVISION USE ONLY

DOPL-AP-069 Rev 2013-08-22

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Division of Occupational and Professional Licensing

160 East 300 South, P.O.Box 146741

Salt Lake City, Utah 84114-6741

FAX: (801) 530-6511

CERTIFICATION OF COMPLETING (24) HOURS OF BASIC CLASSROOM INSTRUCTION FOR ARMORED CAR

(This form must be completed for all armored car security officer applicants.)

TO BE COMPLETED BY APPLICANT:

Name of Applicant:

Social Security Number:					Phone:
Street Address:
City:				State:			Zip:

TO BE COMPLETED BY INSTRUCTOR OF (24) HOURS OF BASIC CLASSROOM INSTRUCTION:

I certify that the above named applicant has successfully completed at least 24 hours of basic classroom instruction consistent with Sections R156-63b-602, 603, and 604 of the Security Personnel Licensing Act Rules for Armored Car. In addition, I certify that the above named applicant achieved at least a minimum score of 80% on the basic education and training final exam in accordance with R156-63b-302d.

Name of Company/Individual Administering Training: (Please Print)

PACSCo ID, or License Number:					Phone Number:
Street Address:
City:				State:		Zip:

Basic Training Score on Final Exam:

Date Applicant Completed the Program: ___/___/___

Name of Program Trainer: (Please Print)

Signature of Program Trainer:

Date: ___/___/___

DOPL-AP-069 Rev 2013-08-22

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Division of Occupational and Professional Licensing

160 East 300 South, P.O.Box 146741

Salt Lake City, Utah 84114-6741

FAX: (801) 530-6511

CERTIFICATION OF COMPLETION OF FIREARMS

INSTRUCTION FOR ARMORED CAR

(This form must be completed for all armored car security officers applicants ONLY.)

TO BE COMPLETED BY APPLICANT:

Name of Applicant:

Social Security Number:					Phone:
Street Address:
City:				State:			Zip:

TO BE COMPLETED BY THE INSTRUCTOR OF THE FIREARMS TRAINING:

I certify that the above named applicant has successfully completed at least six (6) hours of classroom firearms instruction and at least six (6) hours of firearms instruction on the range consistent with Sections R156-63b-602 and 604 of the Security Personnel Licensing Act Rules for Armored Car. In addition, I certify that the above named applicant achieved at least a minimum score of 80% on the practical pistol course.

Name of Company/Individual Administering Training (Please Print):

PACSCo ID, or License Number:					Phone Number:
Street Address:
City:				State:		Zip:

Date Above Named Applicant Completed the Program:

Score on Practical Pistol Course:

Name of Program Trainer: (Please Print)

Signature of Program Trainer:

Date: ___/___/___

DOPL-AP-069 Rev 2013-08-22

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SECURITY PERSONEL APPLICATION

APPLICATION CHECKLIST

(This checklist is for your convenience—do not include it with your application)

Your application is classified as a public record and may be available for inspection by the public, except with regard to the release of information which is subclassified as controlled, private, or protected under the Government Records Access and Management Act or restricted by other law.

The following items are required for a full and complete application:

1.Submit a $100.00 non-refundable application-processing fee, made payable to “DOPL”. The fee is comprised of a $60.00 application fee, a $20.00 surcharge for a BCI fingerprint file search and a $20.00 surcharge for a FBI fingerprint file search.

2.Submit fingerprints to be used by DOPL for a fingerprint search through the files of the Utah Bureau of Criminal Identification (BCI) and the Federal Bureau of Investigations (FBI).

Electronic fingerprinting is offered to DOPL applicants, with no additional charge, at the DOPL office between 8:00 am and 4:30 pm, Mon-Friday, except holidays. A current government issued picture ID is required (driver’s license, state ID, passport, etc.).

If you are unable to obtain fingerprints at DOPL’s office, fingerprint services are available from most local law enforcement agencies. You are required to submit two (2) blue “Applicant” cards (Form FD-258) with your application; these cards will be provided by the agency that rolls your prints.

REVIEW OF YOUR FBI RECORD: If you wish to challenge the accuracy of the information in your FBI record, you should contact the agency that contributed the information in question. You may also direct the challenge to the FBI, Criminal Justice Information Services (CJIS) Division, Attn. SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will forward the challenge to the respective agency.

3.Submit a clear and readable copy of a valid government issued driver's license issued by Washington D.C. or a state of the United States of America or Utah identification card.

4.Submit a “Certification of Completing 24 Hours of Basic Classroom Instruction” form documenting the successful completion of at least 24 hours of basic unarmed classroom instruction consistent with Sections R156-63a-602, and 603 of the Security Personnel Licensing Act Rules

5.Submit a “Certification of Completion of Firearms Instruction” form documenting the successful completion of at least six hours of classroom firearms instruction and at least six hours of firearms instruction on the range consistent with Sections R156-63a-602, and 604 of the Security Personnel Licensing Act rules.

6.Interim Permit Program: An Armed and Unarmed Private Security Officer may immediately start to work upon making application for a period of ninety (90) days if the individual’s criminal record in the state of Utah is clear at the time the individual applies for licensure and if the individual has been issued an Interim Permit Program form by DOPL.

To determine if the applicant’s criminal record in the state of Utah is clear at the time the individual applies for licensure, the applicant must submit with the application an official criminal history report, (Right of Access), from the Bureau of Criminal Identification showing "No Criminal Record Found."

NOTE: If the applicant applies for licensure and has any criminal history record or has marked “Yes” to any question on the Qualifying Questionnaire, an Interim Permit letter will not be issued. The application will be processed in the normal manner and if the application is approved, a temporary license will be issued.

Submit the above items, as well as any supporting documentation, to:

By U.S. Mail			By Delivery or Express Mail
Division of Occupational & Professional Licensing			Division of Occupational & Professional Licensing
P.O. Box 146741			160 East 300 South, 1st Floor Lobby
Salt Lake City, Utah 84114-6741			Salt Lake City, Utah 84111
Telephone Numbers:	(801)	530-6628
	(866)	275-3675 – Toll-free in Utah
Fax Number:	(801)	530-6511

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