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OHIO DEPARTMENT OF PUBLIC SAFETY

PRIVATE INVESTIGATOR SECURITY GUARD SERVICES

1970 West Broad Street

P.O. Box 182001

Columbus, OH 43218-2001

PHONE (614) 466-4130 FAX (614) 466-0342

PISGS

EMPLOYEE REGISTRATION APPLICATION

Use this form to register new employees, file a change-of-name or request a replacement

Affix a 2 x 2 passport style

identification card.

color photograph of the

• Incomplete applications and applications that are filled out improperly will NOT be returned for

registrant no more than

correction.

one year old in this space.

• A check or money order, made payable to Ohio Treasurer of State, MUST be remitted with this

application. Cash is not accepted.

Copies of driver license photos

• If you are applying for initial registration and firearm bearer notation at the same time, this form

are not accepted; no head

gear or sunglasses.

must be used in conjunction with the Firearm-Bearer Notation Application (PSU 0016).

Write the registrant’s name

CLASS OF REGISTRATION

(CHECK ONE)

on the back of the photo and

Private Investigator & Security Guard Registration (A)

affix to this space. Use glue

Private Investigator Registration (B)

or clear tape only.

Security Guard Registration Only (C)

PURPOSE OF APPLICATION

(CHECK ONE)

New Registration / Late Renewal / Rehire w/Rap Back - $ 40.00

Name Change - $ 5.00

Replacement Card - $ 5.00

Class Change - $ 5.00

LICENSEE INFORMATION

COMPANY NAME

LICENSEE FILE #

TRADE NAME (IF APPLICABLE)

ADDRESS (PHYSICAL ADDRESS)

CITY

STATE

ZIP CODE

DAYTIME PHONE #

FAX #

E-MAIL ADDRESS

EMPLOYEE REGISTRATION INFORMATION

FIRST NAME

LAST NAME

SUFFIX

SSN

HOME ADDRESS (NO P.O. BOXES)

PHONE #

DATE OF BIRTH

CITY

STATE

ZIP CODE

COUNTY

CITY OF BIRTH

STATE OF BIRTH

COUNTRY OF BIRTH

HEIGHT

WEIGHT

HAIR COLOR

EYE COLOR

LBS.

HIRE DATE

SCARS AND MARKS

DATE FINGERPRINTS SUBMITTED

AUTHENTICATION #

NAME CHANGE REQUESTS

Complete former name information if applying for a name change. Include copy of new Social Security Card.

FORMER FIRST NAME

FORMER MIDDLE NAME

FORMER LAST NAME

VETERAN INFORMATION

(OPTIONAL)

Are you or your spouse a veteran or active member of the United States Armed Forces?

Yes

If yes, attach a copy of your or your spouse’s DD214 or current military ID for verification purposes.

PUBLIC RECORD AVAILABILITY (Ohio Revised Code [R.C.] 149.43)

Are you currently a commissioned peace officer, parole officer, prosecuting or assistant prosecuting attorney, correctional employee, youth

Yes

services employee, firefighter, EMT, probation officer, bailiff, or an investigator of the bureau of criminal identification and investigation?

CERTIFICATION

I have

I have not been convicted of a felony within the past three years.

I have

I have not been convicted of a misdemeanor within the past twelve months.

By signing this document, I attest that all of the information I have provided is true and accurate to the best of my knowledge. I understand that if I knowingly

make a false statement on this application, I may be subject to criminal prosecution, and potential disciplinary action, including the denial, suspension, or

revocation of my registration. I authorize PISGS to enroll me in the retained applicant fingerprint database and, as a result, I understand PISGS will continually

monitor my criminal history for any new arrest information.

PRINT NAME OF EMPLOYEE

SIGNATURE OF EMPLOYEE

DATE

I have read the information provided by the applicant and have no reason to believe that it is false or misleading.

PRINT NAME OF QUALIFYING AGENT

SIGNATURE OF QUALIFYING AGENT

DATE

PSU 0015 5/14 [760-1525]