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)

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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)

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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)

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

INSTRUCTIONS

Read ALL instructions in this package carefully before completing the application. Incomplete forms will be returned. Any omission, inaccuracy or failure to make full disclosure may be deemed sufficient reason to deny a license or may result in the suspension or revocation of an issued license.

A COMPLETED APPLICATION MUST INCLUDE: (Use this checklist to make sure you have included/completed all requirements.)

□The completed, signed application;

□A signed DMV Informed Consent;

□Receipt that provides proof of electronic fingerprinting by an approved vendor OR

□Rolled FBI (blue) fingerprint card and NYS Request for Card Scan Information Form (DCJS Rev. 11 - 03/04/09);

□Application fee payable to the NYS Department of State. See “Application Requirements -acceptable forms of payment;”

□Applicable fingerprint fees payable to MorphoTrust USA. See “Fingerprint Requirements-acceptable forms of payment;”

□Any additional documentation requested in response to specific questions on the application form;

□Proof of qualifying experience in the form of a sworn statement from each employer under which your experience is claimed, including a

statement of the dates of employment, a description of the specific activities you performed and amount of time spent in those activities;

□Sworn statements from at least three people having direct knowledge of your claimed experience;

□Proof of earnings for at least the last three years of full-time claimed experience, including time and payroll records showing the

number of hours worked and the hourly pay;

□For PI applicants who are claiming experience as a police officer or investigator for a government agency, a letter from the person in

charge of that division or agency indicating your official title, duties performed and length of service in each job title;

□For WGP applicants who are claiming experience as a police officer or security guard for a government agency, a letter from the person

in charge of that division or agency indicating your official title, duties performed and length of service in each job title;

□For applicants who are claiming experience as an employee of a licensed PI or WGP, a copy of your employment application and

Employee Statement;

□For BEA applicants that are claiming experience as a police officer or investigator for a government agency, a letter from the person in

charge of that division or agency indicating your official title, duties performed and length of service in each job title;

□For PI & WGP applicants, the original “PASSED” examination slip (cannot be more than 2 years old)

APPLICATION REQUIREMENTS:

Definition of a Private Investigator (PI):

A Private Investigator conducts investigations to locate the whereabouts of missing persons, finds the location and/or recovers lost or stolen property; finds the causes and origin of, or responsibility for fires, or libels, or losses, or accidents, or injuries to real or personal property. Private Investigators conduct investigations for fee, hire or reward.

Definition of a Bail Enforcement Agent (BEA):

A Bail Enforcement Agent is defined as an individual or entity who (for a fee) apprehends and surrenders individuals on bond or bail (who have failed to appear in court) to jail or to court.

Definition of a Watch, Guard or Patrol Agency (WGP):

A Watch, Guard or Patrol Agency is a company providing security services to protect individuals or property from harm, theft, or other unlawful activity.

License qualifications:

All applicants must be at least 25 years of age at the time of application and be a principal in the business. PI's & WGP's must pass the license examination. You are not eligible to hold a PI or WGP license if you are a holder of an employment agency license, or are a member of a partnership or an officer or a holder of any stock in a corporation or have any financial interest or participation in the control and management of any employment agency.

Please Note: Licensed Private Investigators and their employees can engage in the business of bail enforcement without further licensing requirements or training.

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

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

Experience Required:

The law requires every partner, officer or principal in a business to be licensed to conduct business, and one such individual in each business must provide proof of qualifying experience and pass the license examination.

PI / WGP: “Qualifying” applicants should not submit an application until they pass the appropriate written exam and then must provide proof that they meet one of the following minimum levels of experience, or equivalent position and experience:

Private Investigator applicants must have at least three years of full-time investigative experience as an employee of a licensed private investigator or as an investigator for a government investigative agency or police agency;

OR 3 years of full-time equivalent position and experience acquired in a position where the primary duties were to conduct investigations;

OR 3 years of full-time experience supervising and reviewing the work of at least three people performing investigations; OR 20 years of service as a police officer, regardless of specific title;

OR 20 years of full-time service as a Fire Marshall.

Watch, Guard or Patrol Agency applicants must have at least two years of full-time security experience as a sheriff, police officer, security guard in a government agency or with a licensed PI or WGP;

OR 2 years of full-time equivalent position and experience acquired in a position where the primary duties were the performance of security guard duties;

OR 2 years experience supervising and reviewing the work of at least three people performing security services.

Bail Enforcement Agent applicants must have 3 years experience as a police officer, an investigator in an agency of the state, county or federal government or employee of a licensed private investigator or at a firm, partnership, company or corporation where one member has been performing the duties described in the definition of bail enforcement agent;

OR 20 years experience as a police officer or Fire Marshal.

Training:

There is no specific training required for a PI or WGP. However, a BEA applicant must have completed a training program not less than 25 hours as approved by the Secretary of State. (Training may be waived when the person has served as a police officer for not less than 3 years.)

“Nonqualifier” applicant:

“Nonqualifier” applicants are those partners, officers or principals who are required to be licensed under the law but who do not need to claim qualifying experience in their application. Nonqualifier applicants must submit a completed application, as well as a receipt that provides proof of fingerprint completion.

PI / WGP entities need to be bonded or have insurance:

When your application has been reviewed and approved we will request a $10,000 surety bond. The surety company named on the bond must be duly authorized to do business in New York State and must be recognized and approved by the NYS Superintendent of Insurance.

If you employ security guards, you will also be asked to file evidence of liability coverage in the minimum amount of $100,000 per occurrence and $300,000 in the aggregate and a statement that the coverage includes false arrest or false imprisonment, malicious prosecution, libel, slander and violation of privacy. No security guard company may knowingly employ a security guard unless liability coverage is filed

with the Department of State.

Employers of security guards are also responsible for registering security guards with the Department of State’s Division of Licensing Services. Separate application packages are available for this purpose.

BEA entities need to be bonded:

Yes. When your application has been reviewed and approved we will request a $500,000 surety bond. The surety company named on the bond must be duly authorized to do business in New York State and must be recognized and approved by the NYS Superintendent of Insurance.

Types of licenses:

You must indicate on the top of the application form whether you are applying for a PI, BEA or a WGP license and which type of license:

Individual. You will conduct business solely using your own name and cannot present yourself as being associated with any firm or company.

Trade Name. You will conduct business as a sole proprietorship doing business using a name other than your personal name. The trade name (“d/b/a”) must be filed in the County Clerk’s office of the county in which the business is located. By signing this application, you

are certifying compliance with this requirement.

Partnership. All partners in a partnership must be licensed; separate applications must be completed, signed, and submitted by each partner. At least one partner must meet the qualifying experience and examination requirements and be licensed to conduct business under the partnership name. A partnership certificate must be filed in the County Clerk’s office of the county in which the business is located. By

signing this application, you are certifying compliance with this requirement.

Corporation. All corporate officers (President, Secretary, Treasurer), all holders of 10 percent or more of the stock, and each officer and director working for the corporation within New York State and all other principals must be licensed; separate applications must be completed, signed, and submitted by each such person. At least one corporate officer must be licensed to conduct business under the

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

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

corporate name and at least one principal must meet the qualifying experience and examination requirements and be license. By signing this application, you are certifying compliance with this requirement.

Limited Liability Company, Limited Liability Partnership or Limited Partnership. At least one member or manager of the limited liability company or limited liability partnership must meet the qualifying experience and examination requirements and be licensed to conduct business under the firm’s name. Applicants must be a member, manager or partner prior to licensing. By signing this application, you are certifying compliance with this requirement.

What is the fee and term of licensure? The nonrefundable application fees are:

Private Investigator and Bail Enforcement Agent:

$400 for an individual, proprietary license; plus $400 for each branch office $500 for a corporate or business license; plus $500 for each branch office.

Watch, Guard or Patrol Agency:

$300 for an individual, proprietary license; plus $300 for each branch office $400 for a corporate or business license; plus $400 for each branch office.

Licenses are issued for a two-year period.

A fee of $150 is charged for a change of business name or status.

Acceptable forms of payment:

You may pay by Money Order, Company Check or Cashiers Check made payable to the NYS Department of State. Personal checks or credit cards will not be accepted. Do not mail cash.

FINGERPRINT REQUIREMENTS:

Applicants have access to electronic fingerprinting through IdentoGo by MorphoTrust USA.

Electronic Fingerprinting Procedure:

Applicants may schedule appointments with IdentoGo by MorphoTrust USA. To schedule an appointment at a location near you, visit their website at www.identogo.com or call 877-472-6915.For scheduling purposes, you must utilize the required ORI number NY922020Z.

What to bring to Appointment: Complete the request for NYS Fingerprinting Services - Information Form (pdf) and BRING it with you to the fingerprinting site.

Proof of electronic fingerprint completion: Upon completion of the fingerprint process, the vendor will provide you with two receipts as proof of fingerprint completion. Include one receipt with the completed application. The second copy of the receipt should be retained by your employer.

PLEASE NOTE: Fingerprint receipts are valid for 5 months from the date of fingerprinting. Please submit original application within 5 months from the date of fingerprinting. Failure to submit your application within this time period will require you to complete the fingerprinting process again.

Rolled Fingerprint Card Procedure:

If an electronic fingerprint location does not exist near your residence or place of business and it is not possible to travel to an available site, you may submit a rolled FBI (blue) fingerprint card with your application along with the NYS Request for Card Scan Services - Information form.

Fingerprint fees:

All fees for fingerprinting (including electronic and rolled fingerprint card methods ) are payable to MorphoTrust USA.

•Division of Criminal Justice Services (DCJS) fee: $75.00

•Applicable Fingerprint Vendor fee (Subject to change in January and July of each year) See "e-Fingerprinting" link on top right at www.dos.ny.gov/licensing.

Acceptable forms of payment:

Payment for fingerprint fees must be made in the form of check, money order or credit card payable to MorphoTrust USA.

Note: fingerprint fees are in addition to application fees.

ADDITIONAL REQUIREMENTS:

Employees of Bail Enforcement Agencies who are engaged in the apprehension of individuals are required to be registered as security guards.

If the individuals are also engaged in activities defined as security guard in Article 7-A (§89-g).

Employer Information:

If you are employing security guards, you must separately register those guards by submission of a security guard application. For ALL OTHER STAFF, you must complete and submit a Support Staff/Employee Statement along with proof of fingerprint completion.

Child Support Statement:

If you are applying as an individual (i.e., sole proprietor), a Child Support Statement is mandatory in New York State (General Obligations Law). The law requires you to complete this section — regardless of whether or not you have children or any support obligation.

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

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

Any person who is four months or more in arrears in child support may be subject to having his or her business, professional and driver’s licenses suspended. The intentional submission of a false written statement for the purpose of frustrating or defeating the lawful enforcement of support obligations is punishable under §175.35 of the Penal Law. It is a class E felony to offer a false instrument for filing with a state or local government with the intent to defraud.

PRIVACY NOTIFICATION

The Department of State is required to collect the federal Social Security and Employer Identification numbers of all licensees. The authority to request and maintain such personal information is found in §5 of the Tax Law and §3-503 of the General Obligations Law. Disclosure by you is mandatory. The information is collected to enable the Department of Taxation and Finance to identify individuals, businesses and others who have been delinquent in filing tax returns or may have underestimated their tax liabilities and to generally identify persons affected by the taxes administered by the Commissioner of Taxation and Finance. It will be used for tax administration purposes and any other purpose authorized by the Tax Law and may also be used by child support enforcement agencies or other authorized representatives of this or other states established pursuant to Title IV-D of the Social Security Act, to establish, modify or enforce an order of support, but will not be available to the public. A written explanation is required where no number is provided. This information will be maintained in the Licensing Information System by the Director of Administration and Management, at One Commerce Plaza, 99 Washington Avenue, Albany, NY 12231-0001.

Addresses:

All applicants must list the address where they will be conducting business in New York State. The exclusive use of a post office box number as a business address is prohibited. All business addresses must be located within New York State.

It is important that you notify this division of any changes to your business address so you can continue to receive renewal notices and any other notifications pertinent to your license.

Additional License Restrictions:

License law prohibits the holding of more than one private investigator license. A person cannot be licensed as both a private investigator and a watch, guard or patrol agency. However, a person may have more than one watch, guard or patrol agency license as long as they are not licensed as a private investigator.

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

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