Form Dos 0075 F L A – Fill Out and Use This PDF

FOR OFFICE USE ONLY

UNIQUE ID:		EFFECTIVE DATE:		EXPIRATION DATE:		CASH NUMBER:	FEE:

INSTRUCTIONS: Forms must be completed in blue or black ink. Incomplete forms will not be processed. Please refer to pages 6 - 9 for further instructions on completing this form.

APPLICANT INFORMATION SECTION

APPLICATION AS (Check only ONE): Private Investigator Bail Enforcement Agent Watch, Guard or Patrol Agency Application

I AM APPLYING FOR A LICENSE AS

Individual

Partnership

Trade Name

Corporation

Limited Liability Company

(Check only ONE):

Limited Liability Partnership

Limited Partnership

APPLICANT'S

LAST NAME

FIRST NAME

MIDDLE INITIAL NAME SUFFIX (E.G., Sr./Jr./III)

NAME

RESIDENCE

STREET ADDRESS (Required) - P.O.Box may be added to ensure delivery

APT/UNIT/PO BOX

COUNTY

ADDRESS

CITY

STATE

ZIP+4

CORPORATION NAME (If applicable)

NAME UNDER WHICH YOU WILL BE DOING BUSINESS

PRINCIPAL

STREET ADDRESS (Required)

APT/UNIT/PO BOX

COUNTY

OFFICE

ADDRESS

(New York

Business

CITY

STATE

ZIP+4

Address)

NY

DAYTIME TELEPHONE NUMBER (Optional - If problem with application)

FAX NUMBER (If any)

EMAIL ADDRESS (If any)

SOCIAL SECURITY NUMBER (See Instructions - Privacy Notification)

FEDERAL TAXPAYER ID (See Instructions - Privacy Notification)

OFFICERS OR

NAME

TITLE

PRINCIPALS

NAME

TITLE

NAME

TITLE

NAME

TITLE

NAME

TITLE

DOS-0075-f-l-a (Rev. 06/13)

Page 1 of 9

Private Investigator, Bail Enforcement Agent, Watch, Guard or Patrol Agency Application

BACKGROUND QUESTIONS

➔IF “YES,” you must submit all relevant documents, including the agency determination, if any.

	6. Have you ever applied for a Private Investigator, Bail Enforcement Agent or Watch, Guard or Patrol Agency license	YES	NO
	prior to this application?

RESIDENCE HISTORY (ALL APPLICANTS)

8.Enter below a complete record of your residence(s) during the last 3 years (attach a separate sheet if necessary).

Please type or print clearly.

DATES:ADDRESS:

FROM

TO

STREET ADDRESS

CITY

STATE

ZIP+4

FROM

TO

STREET ADDRESS

CITY

STATE

ZIP+4

FROM

TO

STREET ADDRESS

CITY

STATE

ZIP+4

DOS-0075-f-l-a (Rev. 06/13)

Page 2 of 9

Private Investigator, Bail Enforcement Agent, Watch, Guard or Patrol Agency Application

EXPERIENCE AND OCCUPATION (Qualifying Applicants ONLY)

9.Enter below a complete record of your occupation(s) during the time period during which your qualifying experience is claimed, including the name, address and telephone number of each employer and dates of employment (attach additional sheets if necessary). Also be sure to attach proof of qualifying experience as indicated in this application’s instructions.

NOTE: Failure to provide adequate proof of experience may be grounds for denial of this application.

COMPANY COMPANY NAME

EMPLOYMENT: FROM

TO

ONE

COMPANY ADDRESS

CITY

STATE

ZIP+4

BUSINESS PHONE (Include Area Code)

SUPERVISOR'S NAME

HOURS PER WEEK

Full-Time Part-Time

POSITON / TITLE

DUTIES

COMPANY COMPANY NAME

EMPLOYMENT: FROM

TO

TWO

COMPANY ADDRESS

CITY

STATE

ZIP+4

BUSINESS PHONE (Include Area Code)

SUPERVISOR'S NAME

HOURS PER WEEK

Full-Time Part-Time

POSITON / TITLE

DUTIES

COMPANY COMPANY NAME

EMPLOYMENT: FROM

TO

THREE

COMPANY ADDRESS

CITY

STATE

ZIP+4

BUSINESS PHONE (Include Area Code)

SUPERVISOR'S NAME

HOURS PER WEEK

Full-Time Part-Time

POSITON / TITLE		DUTIES

EXPERIENCE VERIFICATION (Qualifying Applicants ONLY)

10.Enter below the name, address and daytime telephone number of three people who are able to verify your experience.

NAME		DAYTIME PHONE NUMBER (With Area Code)		CITY		STATE		ZIP+4
NAME		DAYTIME PHONE NUMBER (With Area Code)		CITY		STATE		ZIP+4
NAME		DAYTIME PHONE NUMBER (With Area Code)		CITY		STATE		ZIP+4

DOS-0075-f-l-a (Rev. 06/13)

Page 3 of 9

Private Investigator, Bail Enforcement Agent, Watch, Guard or Patrol Agency Application

CHILD SUPPORT STATEMENT (Sole Proprietors ONLY)

11.If you are applying as an individual or a sole proprietor, you MUST complete this section. If you do NOT complete it, your application will NOT be processed.

If you are applying as a Corporation, Partnership or Limited Liability Company, skip to the Applicant Affirmation below.

I, the undersigned, do hereby certify that (You must “X” A or B, below):

A.	I am not under obligation to pay child support. (SKIP “B” and go directly to Applicant Affirmation).
B.	I am under obligation to pay child support (You must “X” any of the four statements below that are true and apply to you):
	I do not owe four or more months of child support payments.
	I am making child support payments by income execution or court approved payment plan or by a plan agreed to by the parties.
	My child support obligation is the subject of a pending court proceeding.
	I receive public assistance or supplemental social security income.

APPLICANT AFFIRMATION (All Applicants)

12.I affirm that I have read and understand the provisions of Article 6D, 7 and 7-A of the General Business Law and the rules and regulations promulgated thereunder (19 NYCRR). I further affirm that Worker's Compensation Insurance/Disability Benefits, for all employees, if applicable, has been secured. I further certify, under the penalties of perjury, that the information given above is true to the best of my knowledge and belief. I understand that any material misstatement made may result in the revocation or suspension of the license, if issued.

X

Applicant's Signature

Date Signed

Print Name:

DMV Consent Section - IMPORTANT INFORMATION Regarding Your Photo ID

13.The Department of State produces photo ID cards in cooperation with the NYS Department of Motor Vehicles (DMV). If you have a current NYS Driver License or Non-Driver ID card, please provide your 9-digit DMV ID Number in the space provided below. Then read the informed consent and sign this form. If you do not have a current NYS photo Driver License or Non-Driver ID card, please have your photo taken at any nearby DMV office BEFORE you complete this application. For more details, refer to our notice, “Request for Photo ID.”

INFORMED CONSENT: I authorize the NYS Department of State and the NYS Department of Motor Vehicles (DMV) to produce an ID card bearing my DMV photo. I understand that DMV will send this card to the address I maintain with the Department of State. I also understand that the Department of State and DMV will use my DMV photo to produce all my subsequent ID Cards for as long as I maintain my license/registration with the Department of State.

DMV ID#	-	-

X

Applicant's Signature

Date Signed

DOS-0075-f-l-a (Rev. 06/13)

Page 4 of 9

Private Investigator, Bail Enforcement Agent, Watch, Guard or Patrol Agency Application

CHARACTER WITNESSES (All Applicants)

14.The law requires five individuals who reside where you reside or where you plan to conduct business sign the following certification:

We, the undersigned, do subscribe and affirm that we are citizens of the United States and reside where the applicant resides or where the applicant conducts or intends to conduct his/her place of business as a private investigator, bail enforcement agent or as a watch, guard or patrol agency. Our business and residence addresses are shown following our names.

We further subscribe and affirm that each of us has personally known the applicant at least five years; we have read the foregoing application for licensure as a private investigator, bail enforcement agent or as a watch, guard or patrol agency and believe each of the statements made therein to be true; that the said applicant is a person of good character and is honest and competent to act as a private investigator, bail enforcement agent or watch, guard or patrol agency; that we recommend his/her application for said licensure be granted; and that we are not related to the applicant by blood or marriage.

We affirm, under the penalties of perjury, that the statements made above are true and correct to the best of our knowledge and belief.

WITNESS	NAME				BUSINESS ADDRESS
ONE
	DAYTIME PHONE NUMBER (Include Area Code)		RESIDENCE ADDRESS (City, State, ZIP)
	SIGNATURE						DATE
	X
WITNESS	NAME				BUSINESS ADDRESS
TWO
	DAYTIME PHONE NUMBER (Include Area Code)		RESIDENCE ADDRESS (City, State, ZIP)
	SIGNATURE						DATE
	X
WITNESS	NAME				BUSINESS ADDRESS
THREE
	DAYTIME PHONE NUMBER (Include Area Code)		RESIDENCE ADDRESS (City, State, ZIP)
	SIGNATURE						DATE
	X
WITNESS	NAME				BUSINESS ADDRESS
FOUR
	DAYTIME PHONE NUMBER (Include Area Code)		RESIDENCE ADDRESS (City, State, ZIP)
	SIGNATURE						DATE
	X
WITNESS	NAME				BUSINESS ADDRESS
FIVE
	DAYTIME PHONE NUMBER (Include Area Code)		RESIDENCE ADDRESS (City, State, ZIP)
	SIGNATURE						DATE
	X

DOS-0075-f-l-a (Rev. 06/13)

Page 5 of 9