Form 45655 - Certification Of Experience Requirement For The Private Detective License - Indiana Professional Licensing Agency

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Private Detective Licensing Board
CERTIFICATION OF EXPERIENCE REQUIREMENT
Indiana Professional Licensing Agency
FOR THE PRIVATE DETECTIVE LICENSE
302 West Washington Street, Room E034
State Form 45655 (R3 / 5-01)
Indianapolis, IN 46204
Telephone: (317) 232-2980
TO BE COMPLETED BY APPLICANT
Name of applicant
Name of employer
Address of employer (number and street, city, state, ZIP code)
Telephone number of employer
Dates of employment:
Position of applicant:
From
To
Applicant's duties:
TO BE COMPLETED BY APPLICANT'S FORMER OR PRESENT EMPLOYER
Name of employer
Address of employer (number and street, city, state, ZIP code)
Name and title of person completing this form:
Authorizing agency license number (if applicable):
According to our records, _____________________________________________
is
was employed as a
Detective
name of applicant
Other _______________________________________
from: _____________________ to ______________________.
Applicant
is
was registered under our agency, registration number: _______________________
Describe below the approximate amount of time (in hours) the applicant was involved in each of the applicant's duties:
The agency issues
W-2's
1099's to employees.
NOTARY CERTIFICATE
I swear to or affirm the truth of the foregoing.
STATE OF
}
SS:
COUNTY OF
I, __________________________________________________ , understand that the above named applicant may be considered for licensure as a private
detective by the Private Detective Licensing Board. Under the penalties for perjury, I state under oath to the Private Detective Licensing Board that the information
reported above is true and correct.
Before me a notary in and for ___________________ county, of _________________ personally appeared ____________________________________ ,
name of agency representative
who swore to the foregoing this day of __________________________ , _________ .
Signature of agency representative
Signature of Notary Public
Printed or typed name of agency representative
Printed or typed name of Notary Public
Date subscribed and sworn to Notary Public
Date commission expires
County of residence

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