Unlicensed And Unregistered Activity Lead Form
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2STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY GOVERNOR EDMUND G. BROWN JR.
BUREAU OF SECURITY AND INVESTIGATIVE SERVICES
Post Office Box 980550
West Sacramento, CA 95798-0550
UNLICENSED AND UNREGISTERED ACTIVITY LEAD FORM
Date/Time: _____________________License Type (select below): ___________________________________
License Number (if applicable): ___________________________________
Note: The Bureau only has jurisdiction over the following Industries:
▪ Alarm
▪ Locksmith
▪ Private Investigator
▪ Repossessor
▪ Training Facilities and Instructors
▪ Private Security Companies
▪ Security Guards
▪ Proprietary Security Officers (In-House Security)
SUBJECT(S) / BUSINESS INFORMATION
Subject’s Name: (First) __________________________________ (Last)______________________________
Subject’s Address
___________________________________________________________________________
Phone Number: ____________________________ Email: __________________________________________
Business Owner’s Name: (First) ___________________________ (Last)______________________________
Business Name(DBA) _______________________________________________________________________
Business Address: __________________________________________________________________________
Phone Number: ___________________________ Alternate Phone Number: ___________________________
LOCATION AND CONTACT INFORMATION OF SUBJECT
Worksite Street Address _____________________________________________________________________
City: _____________________________________ State: _______________________ Zip Code: __________
Cross Streets : _____________________________________________________________________________
Worksite Location: _________________________________________________________________________
Worksite Contact: __________________________________________________________________________
Worksite Phone Number:_____________________________________________________________________
DETAILS OF UNLICENSED ACTIVITY
Describe Unlicensed/Unregistered Activity:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
□
□ This information was provided to me.
This information is from my direct knowledge.
REPORTING PARTY INFORMATION
Name: (First) ____________________________________ (Last)____________________________________
Address __________________________________________________________________________________
Phone Number: ____________________________ Email: __________________________________________
TREAT AS CONFIDENTIAL □Yes or □ No (Check your choice)
PROVIDING PERSONAL INFORMATION IS VOLUNTARY. You do not have to provide the personal information
requested. If you do not wish to provide personal information, such as your name, home address, or home telephone number,
you may remain anonymous. However, the Bureau may have limited ability to help you resolve your complaint.
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