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STATE OF NEW JERSEY

DIVISION OF STATE POLICE

APPLICATION FOR PRIVATE DETECTIVE LICENSE

CASE FILE NUMBER

NAME (Print — Last)			(First)	(Middle)

Home Address		(Street or R.D. Number)		(City)

COUNTY			STATE	ZIP CODE

NAME OF AGENCY and/or TRADE NAME

PRESENT OR	(Number)		(Street or R.D. Number)	(City)
PRESENT OR
PROPOSED
ADDRESS OF AGENCY

COUNTY			STATE	ZIP CODE

MAILING	(Number)		(Street or R.D. Number)	(City)
MAILING
ADDRESS
IF DIFFERENT

COUNTY			STATE	ZIP CODE

HOME PHONE NUMBER

(Area Code/Number)

E-mail

AGENCY PHONE NUMBER
(Area Code/Number)	E-mail

MAIL ALL DOCUMENTS TO:

NEW JERSEY STATE POLICE

PRIVATE DETECTIVE UNIT

P.O. BOX 7068

WEST TRENTON, NEW JERSEY 08628

All license Qualifiers, Corporate Officers, Partners or LLC Members shall complete an application.

Provide all information requested within this application and any other attached forms.

The application shall be completed personally by the applicant.

Any omission or misstatement of fact is grounds for DENIAL - NJAC 13:55-1.11

Any person who shall knowingly state any fact falsely shall be guilty or a misdemeanor - NJS 45:19-11

SP-171 (Rev. 12/00)

CHECK THE APPROPRIATE BOX FOR THE LICENSE TYPE OR POSITION

Individual License Qualifiers*	Corporate License Qualifiers*
	Corporate License Officer

LLC License Qualifiers*	Partnership License Qualifiers*
LLC License Member	Partnership License Non-Qualifiers*

*The Qualifier is that person who has 5 years' experience as an investigator or a police officer.

All Corporate, LLC, and Partnership applications shall be submitted together as one entity.

List the name and address of all Corporate Officers, LLC members, or Partners

Name

Address

NAME OR TRADE NAME

New Jersey Administration Code 13:55-1.6 - Advertising

No licensee shall conduct business under a name or trade name unless authorization has been obtained from the Superintendent of the New Jersey State Police. The Superintendent shall not authorize the use of a trade name which, in his opinion, is so similar to that of a public officer or agency, or that used by another licensee, that the public may be confused or misled thereby. The authorization shall require the filling of a trade name with the County Clerk for an Individual or Partnership license or with the Department of Treasury, Commercial Recording and Business Services for a Corporation or LLC license.

Use of a name different from an individual's name shall require filling with the County Clerk

Out of State Corporations or LLC's shall file with the Department of Treasury

SELECT TWO NAMES

1._______________________________________________________________________________________

2._______________________________________________________________________________________

PHOTOGRAPH

ATTACH CURRENT

FULL FACE PHOTO

No exposure below shoulders

NAME

Last

First

SOCIAL SECURITY NUMBER

DATE OF BIRTH

HEIGHT

WEIGHT

EYE COLOR

HAIR COLOR

RACE

Have you ever held or applied for a Private Detective License in this or any other State? If Yes, state full details.

YES NO

____________________________________________________________________________________________________________

Have you ever been DENIED, or had a Private Detective License REVOKED or SUSPENDED in this or any other State? If Yes, state full details.

YES NO

____________________________________________________________________________________________________________

Have you ever attended, been treated or observed by any doctor or psychiatrist, or at any hospital or mental institution on an impatient or out-patient basis for any mental or psychiatric condition? If Yes, state full details. (Give the name and location of the doctor, psychiatrist, hospital or institution and the dates of occurrence.)

YES NO

____________________________________________________________________________________________________________

Have you been CONVICTED of any Disorderly Persons Offenses or any Criminal Laws of this State or any other jurisdiction? If Yes, state full details. (Offense, Date, Location)

YES NO

____________________________________________________________________________________________________________

UTILIZE THE CONTINUATION PAGE FOR ADDITIONAL DETAILS TO ANY QUESTION

EMPLOYMENT

List All Police or Investigative Employment

(Past & Present)

TO BE COMPLETED BY APPLICANT'S EMPLOYER

EMPLOYING AGENCY

ADDRESS

DATE EMPLOYED FROM - Month/Year

TO - Month/Year

TELEPHONE/E-MAIL

SUPERVISOR NAME/TITLE

SUPERVISOR SIGNATURE

APPLICANT - POSITION/TITLE

REASON FOR TERMINATION OF EMPLOYMENT

EXPLANATION OF APPLICANT'S DUTIES/GENERAL COMMENTS

____________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

TO BE COMPLETED BY APPLICANT'S EMPLOYER

EMPLOYING AGENCY

ADDRESS

DATE EMPLOYED FROM - Month/Year

TO - Month/Year

TELEPHONE/E-MAIL

SUPERVISOR NAME/TITLE

SUPERVISOR SIGNATURE

APPLICANT - POSITION/TITLE

REASON FOR TERMINATION OF EMPLOYMENT

EXPLANATION OF APPLICANT'S DUTIES/GENERAL COMMENTS

____________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

UTILIZE THE CONTINUATION PAGE FOR ADDITIONAL SPACE

* Employer's letterhead stationary, providing the same information, may substitute for this form*

REFERENCES

The applicant shall insure that five reputable citizens, unrelated to the applicant and over the age of 21, complete the following information and provide a signature attesting to the approval of the applicant.

A reference shall only complete and sign if offering approval of the applicant's character and competency to be licensed as a New Jersey Private Detective.

1.	PRINT NAME	HOME PHONE	WORK PHONE

ADDRESS			E-MAIL

SIGNATURE			DATE

2.	PRINT NAME	HOME PHONE	WORK PHONE

ADDRESS			E-MAIL

SIGNATURE			DATE

3.	PRINT NAME	HOME PHONE	WORK PHONE

ADDRESS			E-MAIL

SIGNATURE			DATE

4.	PRINT NAME	HOME PHONE	WORK PHONE

ADDRESS			E-MAIL

SIGNATURE			DATE

5.	PRINT NAME	HOME PHONE	WORK PHONE

ADDRESS			E-MAIL

SIGNATURE			DATE

AUTHORIZATION FOR RELEASE OF INFORMATION

TO WHOM IT MAY CONCERN:

I, ____________________________________, AM HAVING A CONFIDENTIAL BACKGROUND

PRINT NAME

INVESTIGATION CONDUCTED ON ME BY THE NEW JERSEY STATE POLICE.

THEREFORE, I AUTHORIZE A REVIEW, FULL DISCLOSURE, AND RELEASE OF ALL RECORDS OR INFORMATION, OR ANY PART THEREOF, CONCERNING MYSELF TO ANY SWORN MEMBER OF THE NEW JERSEY STATE POLICE, WHETHER THE SAID RECORDS OR INFORMATION ARE PUBLIC OR PRIVATE, AND INCLUSIVE OF RECORDS OR INFORMATION CONSIDERED PRIVILEGED OR CONFIDENTIAL IN NATURE.

THE RELEASE AUTHORIZATION IS INTENDED TO PROVIDE A RELEASE OF ANY INFORMATION THAT CAN BE UTILIZED AS INVESTIGATIVE RESOURCE MATERIAL DURING THE BACKGROUND INVESTIGATION FOR A NEW JERSEY PRIVATE DETECTIVE LICENSE, AND DURING AN INDIVIDUAL'S ENTIRE LICENSE PERIOD. THE RELEASE WILL REMAIN IN EFFECT DURING THE INITIAL LICENSE PERIOD AND SUBSEQUENT LICENSE RENEWAL PERIODS.

A PHOTOSTATIC COPY OF THIS AUTHORIZATION WILL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.

SIGNATURE MUST BE NOTARIZED

I,________________________________________________________ AFFIRM THAT I AM THE ABOVE

PRINT NAME

NAMED PERSON MAKING APPLICATION FOR A NEW JERSEY PRIVATE DETECTIVE LICENSE. I READ AND ANSWERED EACH QUESTION WITHIN THE APPLICATION COMPLETELY AND TRUTHFULLY.

_________________________________________________

APPLICANT SIGNATURE

DATE

Sworn to before me this

___________________________ day of ________________________, _________

YEAR

__________________________________________________

Notary Public

CONTINUATION PAGE

_________________________________________________________________________________________________________

_________________________________________________________________________________________________

__________________________________________________________________________________________________