State Form 43777 - Application For Private Detective License

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MARK APPROPRIATE BOX

APPLICATION FOR PRIVATE DETECTIVE LICENSE

Renewal of License Number ______________

State Form 43777 (R6 / 6-00)

Original Application for licensure

Approved by State Board of Accounts 2000

INSTRUCTIONS:

* Your Social Security number and/or Federal Identification

1 .

New applicants: Complete Items 1-22, 29-41, and the Affidavit.

Indiana Professional Licensing Agency

number is requested in accordance with the provisions of

Attach a recent photograph of yourself in the designated area

Private Detective Licensing Board

IC 4-1-8-1. Disclosure is mandatory. The number will be

on Page 3, complete the vital statistics information and attach

302 West Washington Street, Room E034

given t o the I ndiana Depart ment of R ev enue.

fingerprints.

Indianapolis IN 46204-2700

2 .

Renewals: Complete Items 1-6, 23-28, and the Affidavit.

Pursuant to IC 25-30-1, concerning the regulation and licensing of the private detective business and private detectives in the State of Indiana, the following

questions shall be answered, and the required information given, by each individual applicant and, if the applicant is a corporation or partnership, its officers

or partners for Private Detective License.

Use a separate sheet of paper to com plete answers to any question, if necessary.

APPLICANT INFORMATION

1. Name of applicant (type or print)

2. Social Security number *

3. Position of applicant (state either "Individual" or name of position held)

4. Name under which applicant intends to do business

5. Business Address (number and street)

Business telephone number

(

)

City, state, ZIP code

6. Resident address (number and street)

Resident telephone number

(

)

City, state, ZIP code

9. If a Corporation applicant, have all statutory

7. Date of birth

8. How long have you been a resident of Indiana?

prerequisites to the doing of business in Indiana

Yes

been satisfied?

10. Federal identification number *

(ATTACH A CO PY OF CORPO RATE FILING S)

EDUCATION INFORMATION

11. Name of high school (if a graduate)

Address (number and street, city, state, ZIP code)

12. College(s) attended

14. Degree received

13. College from which degree received

15. List post-graduate degree(s), if any, and schooling which you have completed and consider to better qualify you for purposes of this application.

CRIMINAL RECORD INFORMATION / SUBMISSIONS

FOR NEW APPLICATIONS ONLY

16. Have you, any employee, or if a corporation or partnership, its officers, directors, partners, employees or members ever

been convicted of any crime? (If YES, on back page, state what crime[s], name and location of court[s] of conviction, the

Yes

sentence[s] of the court[s], and attach documentation of conviction[s].)

17. Have you, any employee, or if a corporation or partnership, its officers, directors, partners, employees or members ever

been convicted of any act which, under the provisions of the Indiana Detective License Law (IC 25-30-1), would be

grounds for denial, suspension, or revocation of a private detective license? (If YES, on back page, state what crime[s],

Yes

name and location of court[s] of conviction, the sentence[s] of the court[s], and attach documentation of conviction[s].)

SUBMISSIONS REQUIRED FOR NEW APPLICATIONS

18. Submit original copies of your, or if a corporation or partnership, its officers or partners, review challenge (limited criminal history) received from

the applicable state and local police records (city and county of residence).

19. Registration of each employee shall be filed with a completed identification card and a ten dollar ($10) fee.

20. Any applicant employing more than fourteen (14) employees shall submit proof of one hundred thousand dollars ($100,000) per occurrence liability

insurance. Applicants employing less than fifteen (15) employees shall submit proof of seven thousand dollars ($7,000) surety bond, or proof of one

hundred thousand dollars ($100,000) per occurrence liability insurance.

2 1 . Recent photo.

2 2 . Set of fingerprints of both hands, taken by a police official.