Application For License As Professional Bondsman - State Of Connecticut Department Of Emergency Services And Public Protection
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1
2State of Connecticut
Department of Emergency Services and Public Protection
Division of State Police
Special Licensing and Firearms Unit
APPLICATION FOR LICENSE AS PROFESSIONAL BONDSMAN
INSTRUCTIONS TO APPLICANTS
For Office use only:
1.
Complete by printing or typing in all entries, using black ink only.
Date of Application:
____/____/____
2.
If a “Yes” is checked use plain 81/2 x 11 paper for additional space.
3.
Include a $ 200.00 certified check or money order for Bondsman
License #:
license, made payable to Treasurer, State of Connecticut.
4.
Include 2 X 2 full face color passport type photo with blue background
Name of Applicant:
Last Name
First Name
MI
List all other names by which you have been known
( Maiden Name, Aliases, Nicknames, etc.):
Residential Address
(Do not use a P.O. Box Number):
Number
Street
City/Town
State
ZIP Code
Bondsman Business Name (If any)
Business Phone #
Business Address Mandatory
(for public information use, P.O. Box number acceptable)
Number
Street
City/Town
State
ZIP Code
Date of Birth
Race
Sex
Height
Weight
Hair Color
Eyes Color
Home Telephone
(
)
Place of Birth
Social Security Number
Operator License Number/Issuing State
(City/Town/Country)
CITIZENSHIP
Are you a citizen of the United States?
YES
NO
(If Naturalized, state when and where):
MEDICAL HISTORY
Have you ever been committed to or confined in a Hospital for a Mental Illness?
YES
NO
(If Yes, explain):
Have you ever received care or treatment for any mental, psychiatric, psychological illness or disorder?
YES
NO
(
If Yes, explain):
Have you been discharged from custody, within the past twenty (20) years, after having been
found not guilty of a crime by reason of mental disease or defect ? (If Yes, explain):
YES
NO
EMPLOYMENT HISTORY
Provide the following information about your present employer:
(If you are not employed, provide information of your most recent employer)
Company Name
Address (Street, City, State, ZIP Code)
Supervisor Name
Telephone No.
Are you retired or separated from a Local or State Police Department?
YES
NO
(If Yes, a letter of discharge from the employer describing the length of service, duties and date of retirement or separation must be attached)
YES
NO
Are you currently applying or interviewing for a Federal, State or Local Police Department. (If yes, whom and where)
Are you presently vested with Police Powers?
YES
NO
MILITARY SERVICE
Were you ever discharged from the Armed Forces of the United States with a less than Honorable Discharge?
(I
f
YES
NO
Yes, explain. If you performed military service attach a copy of your Form DD-214 or NGB-22 must be attached
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