State Form 47241 - Application For Authorized Employee / Private Detective License Action - Indiana Professional Licensing Agency

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APPLICATION FOR AUTHORIZED EMPLOYEE /
Indiana Professional Licensing Agency
PRIVATE DETECTIVE LICENSE ACTION
Private Detective Licensing Board
302 West Washington Street, Room E034
State Form 47241 (R2 / 4-00)
Indianapolis, Indiana 46204-2277
Form approved by State Board of Accounts, 2000
* Your Social Security number is requested under IC 4-1-8-1; disclosure is
mandatory and this record cannot be processed without it.
Action:
Issuance fees:
Issue card
Terminate license
$10.00 If employer license valid for more than 12 months.
$5.00 If employer license valid less than 12 months.
All fees are non-transferable and non-refundable per IC 25-1-8-2(e)
APPLICANT INFORMATION
Name of applicant
Employee license number
Address (number and street, city, state, ZIP code)
Date of birth (month, day, year)
Social Security number*
Signature of applicant
Date signed (month, day, year)
EMPLOYER INFORMATION
Name of agency
LEAVE BLANK
License number
Expiration date (month, day, year)
Typed name of agency manager
Daytime telephone number
(
)
Signature of agency manager
APPLICATION FOR AUTHORIZED EMPLOYEE /
Indiana Professional Licensing Agency
PRIVATE DETECTIVE LICENSE ACTION
Private Detective Licensing Board
302 West Washington Street, Room E034
State Form 47241 (R2 / 4-00)
Indianapolis, Indiana 46204-2277
Form approved by State Board of Accounts, 2000
* Your Social Security number is requested under IC 4-1-8-1; disclosure is
mandatory and this record cannot be processed without it.
Action:
Issuance fees:
Issue card
Terminate license
$10.00 If employer license valid for more than 12 months.
$5.00 If employer license valid less than 12 months.
All fees are non-transferable and non-refundable per IC 25-1-8-2(e)
APPLICANT INFORMATION
Name of applicant
Employee license number
Address (number and street, city, state, ZIP code)
Date of birth (month, day, year)
Social Security number*
Signature of applicant
Date signed (month, day, year)
EMPLOYER INFORMATION
Name of agency
LEAVE BLANK
License number
Expiration date (month, day, year)
Typed name of agency manager
Daytime telephone number
(
)
Signature of agency manager

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