Security Guard Training School Notification Of Changes Form Page 2

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New York State Division of Criminal Justice Services

Office of Public Safety/Security Guard Program

80 South Swan Street, Albany, NY 12210

SECURITY GUARD TRAINING SCHOOL NOTIFICATION OF CHANGES

PART II

School Name:

School Identification Number:

Change to School Owner

Department of State License Number or UID

Federal Tax ID Number/Employer ID Number:

School Owner or Corporation Name:

If Corporation, Contact Name and Title:

Street Address

City, State, Zip Code

Telephone Number

(area code + number)

If sole owner (proprietor) of school provide the following:

Gender

Date of Birth

*Social Security Number

Email Address

Has the SCHOOL OWNER ever been affiliated with or owned any security guard school?

Yes

If yes, please provide full details attached to this application, including any disallowances, fines, or any other disciplinary action against them or the school by any

Local, State or Federal authorities.

Change to (check one):

School Director

School Co-Director

Partner

Name

Gender

*Social Security Number

Department of State License Number or UID

Telephone Number

Email Address (REQUIRED)

(area code + number)

Have you ever been affiliated with or owned any security guard school?

Yes

If yes, please provide full details attached to this application, including any disallowances, fines, or any other disciplinary action against them or the school by any

Local, State or Federal authorities.

Disclosure (School Owner, School Director, School Co-Director, Partner)

Have you ever been convicted in this state or elsewhere of a crime, misdemeanor or a felony?

Yes

If yes, you must submit with this application a written explanation giving the place, court jurisdiction, nature of the offense, sentence and/or other disposition. You

must submit a copy of the accusatory instrument (e.g., indictment, criminal information or complaint) and a Certificate of Disposition. I f you possess or have

received a Certificate of Relief from Disabilities, Certificate of Good Conduct or Executive Pardon, you must submit a copy with this application.

Are there any criminal charges (misdemeanors or felonies) pending against you in any court in this state or elsewhere?

Yes

If yes, you must submit a copy of the accusatory instrument (e.g., indictment, criminal information or complaint).

Has any license, permit, commission, registration or application for a license, permit, commission, or registration held by you or a company in which you are or

were a principal or employee In New York State or elsewhere ever been revoked, suspended or denied by any state, territory or governmental jurisdiction or

foreign country, for any reason?

Yes

If yes, you must submit all relevant documents, including the agency determination, if any.

Affirmation: This affidavit must be signed and sworn to by the signer before a Notary Public.

I hereby affirm, under penalties of perjury, that the information provided in this application is true to the best of my knowledge and belief. I understand that any

material misstatement may be deemed sufficient reason to deny approval, or may result in the suspension or revocation of the school approval, if issued. I hereby

acknowledge that I have thoroughly read and understand General Business Law section 89-n and Parts 6027, 6028, and 6029 of Title 9 of the NYS Official

Compilation of Codes, Rules and Regulations. I further understand that DCJS may ask for additional information/documentation.

For School Director: I further understand that as the School Director I must attend the School Director Orientation Seminar if required by the Division of Criminal

Justice Services (DCJS).

Notary Stamp

Printed Name

Sworn and subscribed before me

this _______day of _______________ 20_______

Signature

Date

Notary Signature

*Attach additional sheets as required

NEW YORK STATE DIVISION OF CRIMINAL JUSTICE SERVICES August 2011