Form Psg-690-013 - Application For Examination Or Re-Examination As A Certified Trainer - State Of Washington

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PRIVATE SECURITY GUARD SECTION
STATE OF WASHINGTON
STATE OF WASHINGTON
BUSINESS AND PROFESSIONS DIVISION
Department of
Department of
P.O. BOX 9649
OLYMPIA, WA 98507-9649
FOR VALIDATION ONLY
APPLICATION FOR EXAMINATION OR RE-EXAMINATION
AS A
CERTIFIED TRAINER
Make remittance payable to: STATE TREASURER
Check one:
Unarmed Private Security Guard
(001-070-2990010)
FEE: $25.00
Armed Private Security Guard
(001-070-2990011)
PLEASE TYPE OR PRINT CLEARLY
Name ___________________________________________________________________________________________
LAST
FIRST
MI
Business Address _________________________________________________________________________________
STREET
City _____________________________ State ___________ Zip _____________ County ____________________
Company Name __________________________________________________________________________________
Applicant's Personal Identifier Code (PIC) __________________________________ Birthdate ___________________
/
/
(APPEARS ON TOP RIGHT OF RESULT LETTER—12 DIGIT LETTER/NUMBER COMBINATION)
Applicant's Home Address: __________________________________________________________________________
City _____________________________ State ___________ Zip __________________ County ______________
Current License Number (from top of license):
Unarmed—299-10 _____________________________________
Armed—299-11 _______________________________________
____________________________________________
SIGNATURE OF APPLICANT
Date ___________________________
/
/
FOR OFFICE USE ONLY
Exam Date ______________________
Exam I.D. # ______________________
/
/
/
/
Result:
Pass
Fail
Score _________ %
Exam Date ______________________
Exam I.D. # ______________________
/
/
/
/
Result:
Pass
Fail
Score _________ %
PSG-690-013 CERT TRAINER EXAM/RE-EXAM (R/4/98)M/W

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