Form Psb 12 – Fill Out and Use This PDF

Texas Department of Public Safety

Private Security Bureau

PO Box 15999, Austin, Texas 78761-5999

www.txdps.state.tx.us

APPLICATION FOR PERSONAL PROTECTION OFFICER (BODY GUARD) AUTHORIZATION

I am at least 21 years of age.

I am not addicted to drugs or alcohol, have never been arrested, charged, indicted, entered into a pre-trial diversion agreement, placed on deferred adjudication, placed on probation or convicted of any Class A misdemeanor or felony, or Class B misdemeanor within the last (5) five years.

I am mentally competent, and, if in the military, I was discharged under honorable conditions.

I will not carry a concealed firearm unless I apply for and receive a personal protection officer authorization from the Private Security Bureau.

Please complete and submit the following items:			Qualifications:
1.	$50.00 Application Fee + $5.00 Subscription Fee= $55.00	1. Employed by a licensed guard or investigations company
2.	Level Four Personal Protection Officer Certificate of Completion	2.	Completed PSB Levels 2, 3 and 4 training courses
3.	Completed Declaration of Psychological and Emotional Health	3.	Currently have, or are applying for a security officer commission
4.	Current handgun proficiency certificate (within last 90 days)

Note: Fee(s) submitted by mail, must also have a PSB-50 form attached.

Fees submitted to the Private Security Bureau are not refundable or transferable.

Employment Hours:( ) Full Time( ) Part Time

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PLEASE TYPE OR PRINT CLEARLY

Company Name: ______________________________________________ Company License Number: _____________

Company Address: ____________________________________________________ Company Phone: ___________________

Number & Street	City	State	Zip	area code + number
Social Security Number: ___________________________			TX Driver License or TX ID: _____________________

Name: __________________________________________________________________________________________________

LastFirstMI

Home Address: ________________________________________________________ Home Phone: _____________________

	Number & Street			City	State	Zip		area code + number
Date of Birth: __________________				Place of Birth: ______________________________________
						City/State or Country
Sex (circle one):	1. Male		2. Female	Height/Weight:		Feet: ______ Inches: ______ Pounds: _________
Eyes (circle one):	1.	Blue	2. Brown	3. Gray	4. Hazel		5. Green	6. Black
Hair (circle one):	1.	Black	2. Red	3. Gray	4. Brown		5. Blonde	6. Bald
Race (circle one):	1. White		2. Black	3. Spanish	4. Amer. Indian		5. Asian	6. Other________________

List any alias you have used: _______________________________________________________________________________

Applicant’s Signature:___________________________________________ Date:______________________

This section must be completed by the Qualified Manager or Owner

I hereby verify that the above applicant began employment in a position that requires registration with my company on:

__________________________________

Applicant’s Date of Employment

I am requesting that the above applicant be issued a personal protection authorization with my company as my employee.

Qualified Manager or Owner Signature: ___________________________________ Date: _________________

NOTICE: THIS IS A GOVERNMENTAL RECORD.

ANY FALSE ENTRY MADE ON THIS DOCUMENT COULD BE CONSIDERED A CRIMINAL VIOLATION.

PSB-12

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Rev. 10/12/09