Form Psg-690-001 - Application For Licensure As A Private Security Guard Company/principal Form
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1
2Business and Professions Division
Application for Licensure as a
Private Security Guard Licensing
PO Box 9649
PRIVATE SECURITY GUARD COMPANY/PRINCIPAL
Olympia, WA 98507-9649
Copy a blank of this form for completion by company partner(s)
Check the type(s) of licensure for which you are applying:
FOR VALIDATION ONLY
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Unarmed principal & company - $250
Armed principal & company - $265
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Unarmed partner - $53
Armed partner - $77
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Change of unarmed principal - $53
Change of armed principal - $77
Make checks payable to: STATE TREASURER
001-070-299-0009
Company Information
Company Name
Telephone
FAX
Business Address (number, street, and suite or room number)
City
State
Zip Code
County
Business Mailing Address (if different)
City
State
Zip Code
County
Type of Business (check one)
Number of Partners (if partnership)
UBI No. (if corporation)
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Sole owner
Partnership
Corporation
Foreign corp.
Branch Office Address (street, city, state, zip)
Branch Office Address (street, city, state, zip)
Branch Office Address (street, city, state, zip)
Principal/Partner Information
Principal/Partner Name (last, first, middle initial)
Maiden Name or Aliases
Telephone
Home Address (number, street, apartment number)
City
State
Zip Code
County
Date of Birth
Sex (check one)
Social Sec. No. (required per RCW 26.23.150) Citizenship Status (check one)
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Female
Male
US Citizen
Resident Alien
Requirement under which you will be qualifying for licensure (check one)
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Examination
3 years’ experience as manager, supervisor, or administrator in the private security business or a related field
Legal Profile -
attach requested documents and a separate explanation sheet for “Yes” answers
Applicant–respond to all questions below. If you answer “yes” to any, attach a separate sheet with explanation.
Yes No
Yes No
5.
Have you ever been convicted of any act involving
1.
Have you ever been found guilty of, or held liable
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unethical or immoral behavior?
for, fraud, dishonesty, or misrepresentation while
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performing duties as a private security guard?
6.
Have you been licensed as a security guard in
any jurisdiction? If "yes," in what jurisdiction?
2.
Have you ever been found guilty of, or held liable for,
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(Please insert name of state, county, or city
incompetence or negligence that resulted in injury
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______________________________
to a person or created an unreasonable risk to a
and date __________________)
person?
3.
Have you ever been found guilty of, or held liable for,
7.
Have you ever had a security guard license
releasing information about the property or valuables
suspended, revoked, or restricted? If "yes," in
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what jurisdiction? (Please insert name of state,
you were guarding?
county,
or
city
4.
Have you ever been convicted of a gross
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misdemeanor or felony?
and date__________________)
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
you need special accommodation, please call (360) 664-9072 or TTY (360) 586-2788.
PSG-690-001 PSG CO/PRIN APP (R/6/00)FM/W Page 2 of 3
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