Application For Licensure - 1998
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1
2Business and Professions Division
Private Security Guard Section
PO Box 9649
Unarmed Private Security Guard
Olympia, WA 98507-9649
Application for licensure
New applicant $53
Transfer/Rehire $20
FOR VALIDATION ONLY
(submit renewal fee, if due)
Make checks payable to: STATE TREASURER
Please type or print clearly and sign on reverse
001-070-299-0010
Applicant's name (last, first, middle)
Date of birth
Applicant's residence address (street)
City
State
Zip
Home telephone
(
)
Social Sec. No. (required -RCW26.23.150)
Sex
U.S. Citizen
Resident Alien
M
F
Temporary card number
Date issued
Expires on (60 days)
Business name
Business address (street)
City
State
Zip
County
Business telephone
Fax
(
)
(
)
Certification of Preassignment Training/Testing
This is to certify that __________________________________________________________________________________ has
Applicant name
successfully completed the preassignment training and testing requirements as outlined in WAC 308-18-300. Incorrectly answered
questions were reviewed with the applicant and the test results have been verified and signed by me.
X
_________________________________________________
_________________________________________________
Printed name of certified trainer
Signature of certified trainer
/
/
Date ______________________________
Applicant - respond to all questions below. If you answer "yes" to any, attach a separate sheet with explanation.
Yes
No
1.
Have you ever been found guilty of, or held liable for, fraud, dishonesty, or misrepresentation while performing duties
as a private security guard?
2.
Have you ever been found guilty of, or held liable for, incompetence or negligence that resulted in injury to a person
or created an unreasonable risk to a person?
3.
Have you ever been found guilty of, or held liable for, releasing information about the property or valuables you were
guarding?
4.
Have you ever been convicted of a gross misdemeanor or felony?
5.
Have you ever been convicted of any act involving unethical or immoral behavior?
6.
Have you been licensed as a security guard in any jurisdiction? If "yes," in what jurisdiction? (Please insert name
of state, county, or city ______________________________ and date __________________)
7.
Have you ever had a security guard license suspended, revoked, or restricted? If "yes," in what jurisdiction? (Please
insert name of state, county, or city ______________________________________
and date_____________________)
sign on page 2
If any conviction was dismissed, please enclose copies of the court documents.
The Department of Licensing has a policy of providing equal access to its services. If
PSG-690-008 U/A PRI. SEC. GD. APP. (R/11/98)FM/W Page 1 of 2
you need special accommodation, please call (360)664-9072 or TTY (360)586-2788.
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