Free 53325.FH11 - Indiana

APPLICATION FOR LICENSURE AS A PRIVATE INVESTIGATOR FIRM
State Form 53325 (8-07) Approved by State Board of Accounts, 2007

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PRIVATE INVESTIGATOR AND SECURITY GUARD LICENSING BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis IN 46204-2700 Telephone: (317) 234-3040 www.pla.in.gov

APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER DATE LICENSE ISSUED (month, day, year)
* Your Social Security number and/or Federal Identification number is requested in accordance with the provisions of IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it. Social Security Numbers may be made available to the Indiana Department of Revenue. DO NOT WRITE ABOVE THIS LINE

One (1) photograph required. Recent head and shoulder 2 X 2 photo must be attached to application. Photo must be of passport quality.

Type of application (check one)

New Private Investigator Firm License

New Qualifier for Existing Licensed Private Investigator Firm

FIRM QUALIFIER INFORMATION
Name of firm qualifier (last, first, middle, maiden or previous) Address of resident (number and street, city, state and ZIP code) Telephone number of resident (include area code) ( ) Place of birth (city, state) Social Security number * Date of birth (month, day, year) E-mail address

List any additional residential addresses within previous seven (7) years

FIRM INFORMATION
Name of firm (under which firm currently does business or intends to do business) Position of applicant / firm qualifier (state individual if sole practitioner or name position title within firm) Address of firm (number and street, city, state and ZIP code) Website of firm (URL) Federal identification number Indiana license number of firm (if new qualifier) Telephone number of firm (include area code) ( )

If the firm has registered as a Corporation, Limited Liability Company, or Partnership, have all statutory prerequisites been satisfied in order to conduct business in Indiana? (If yes, attach a copy of corporate filings**) **Any out-of-state company that wishes to do business in Indiana must register as a Foreign Corporation with Indiana Secretary of State. Please submit verifying documentation of your Foreign Corporation registration along with this application. Page 1 of 4

Yes

No

FIRM LIABILITY INSURANCE INFORMATION Applicants must attach an original or notarized copy of their Certificate of Insurance.
Name of insurance provider Telephone number of insurance provider (include area code) ( ) Policy number

FIRM QUALIFIER EDUCATION INFORMATION Applicants intending to use a college degree as qualification for licensure must submit an original academic transcript.
Name of college or university from which the degree was received Type of degree received List any post -graduation degrees earned, if any, and any additional educational experience you have which you consider to better qualify you for purposes of this application Year of graduation

List any national certifications or credentials you have obtained which you consider to better qualify you for purposes of this application

FIRM QUALIFIER EMPLOYMENT EXPERIENCE INFORMATION In addition to completing this section, applicants must also have the verification of experience form completed and submitted by their employer.
Name of present employer Address of present employer (number and street, city, state and ZIP code) If unemployed, name of most recent employer Address of most recent employer (number and street, city, state and ZIP code) Duties in present, or most recent, position

Have your ever been employed by a Licensed Private Investigator Firm or a Licensed Security Guard Agency in Indiana (previously called a Private Detective Agency License) or any similar license in any other state? (If yes, provide name of licensed firm(s), city and state of licensed firm(s), state(s) of firm licensure, firm license number(s) and dates of employment. Use a separate sheet of paper if more room is needed.)
Name of licensed firm or agency Name of licensed firm or agency Name of licensed firm or agency City and state City and state City and state State of licensure State of licensure State of licensure Firm or agency license number Firm or agency license number Firm or agency license number

Yes

No

Date(s) of employment (month, day, year) Date(s) of employment (month, day, year) Date(s) of employment (month, day, year)

Have your ever been employed by a law enforcement agency in Indiana or any other state? (If yes, provide name of law enforcement agency, city and state, and dates of employment. Use a separate sheet of paper if more room is needed.)
Name of law enforcement agency Name of law enforcement agency Name of law enforcement agency City and state City and state City and state

Yes

No

Date(s) of employment (month, day, year) Date(s) of employment (month, day, year) Date(s) of employment (month, day, year)

List your previous employment experience which you believe would qualify you as a qualifier for a Private Investigator Firm license.

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PRIVATE INVESTIGATOR FIRM VERIFICATION OF EXPERIENCE
Part of State Form 53325 (8-07) Approved by State Board of Accounts, 2007

PRIVATE INVESTIGATOR AND SECURITY GUARD LICENSING BOARD PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis IN 46204-2700 Telephone: (317) 234-3040 www.pla.in.gov

SECTION I: APPLICANT / FIRM QUALIFIER INFORMATION (to be completed by the applicant)
Name of applicant / firm qualifier (last, first, middle, maiden or previous) Name of employer Address of employer (number and street, city, state and ZIP code) Telephone number of employer (include area code) ( ) Dates of employment (month, day, year) From Duties of applicant / firm qualifier To Position of applicant / firm qualifier E-mail address of employer

(to be completed by the former or present employer of the applicant and submitted directly to the Indiana Professional Licensing Agency by the employer)
Name of employer Address of employer (number and street, city, state and ZIP code) Name of person completing this form Title of person completing this form License number of employer (if applicable)

SECTION II: APPLICANT / FIRM QUALIFIER EMPLOYMENT INFORMATION

According to our records, _______________________________________________________________________ , Investigator Security Guard

is

was employed as an

Other _____________________________________ from __________________ to _________________.
(month, day, year) (month, day, year)

Describe the approximate amount of time (in hours) the applicant was involved in each of the duties

This company issues

W-2s

1099s to employees NOTARY CERTIFICATE

STATE OF COUNTY OF I,
Signature of individual completing SECTION II of this form Printed or typed name of individual completing SECTION II of this form Date subscribed and sworn to Notary Public

}

SS:

, having been duly sworn on oath, say that I am the
Signature of Notary Public Printed or typed name of Notary Public County of residence Date commission expires (month, day, year)

above-named, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.

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OTHER STATE LICENSURE / CERTIFICATION / REGISTRATION / PERMIT APPLICANTS WHO HAVE HELD ANY TYPE OF PROFESSIONAL LICENSE IN INDIANA, OR ANY OTHER STATE, WITHIN THE TEN (10) YEARS PRECEDING THE FILING OF THIS APPLICATION FOR LICENSURE MUST LIST THOSE LICENSES BELOW. FURTHER, APPLICANTS MUST REQUEST THAT THE STATE(S) WHERE LICENSES ARE OR HAVE BEEN HELD SUBMIT OFFICIAL LICENSE VERIFICATIONS DIRECTLY TO THE INDIANA PROFESSIONAL LICENSING AGENCY. Do you now hold, or have you held, a license / certificate / registration / permit to practice or perform any regulated profession by a state licensing board? (Examples would include private investigator or security guard licenses in other states, real estate licenses, health-profession licenses, etc. This does not include liqueur licenses, substitute teacher licenses or any other license that was not issued by a state regulatory licensing board or commission.) Yes No (If yes, list all states below, including Indiana, in which you have held license / certification / registration / permit.) STATE LICENSE NUMBER DATE ISSUED LICENSE STATUS

TYPE OF LICENSE / CERTIFICATE / REGISTRATION / PERMIT

If you answer Yes to any question below, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date and disposition. Include all relevant court documents if applicable. Letters from attorneys are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a license issued pursuant to this application. ALL APPLICANTS 1. Have you ever been convicted of, pled guilty or nolo contendre to any offense, misdemeanor or felony in any state, or by the Federal courts, or any agency of government, or are criminal charges now pending against you (except for minor violations of traffic laws resulting in fines); and are you currently facing any unadjudicated misdemeanor or felony charges? 2. Have you ever been denied a license, certification, registration or permit to practice private investigatory work or any other profession in this or any other state? 3. Has any complaint been filed against you in the State of Indiana, or in any other state, regarding any professional license you currently hold or have previously held or have you practiced private investigatory work as defined by IC 25-30 without a license? 4. Has disciplinary action ever been taken regarding any professional license, certification, registration, or permit that you currently hold or have previously held? APPLICANT AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date of signature (month, day, year)

Yes

No

Yes

No

Yes

No

Yes

No

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request, and direct any person, firm, officer, corporation, association, organization or institution to release to the Indiana Professional Licensing Agency, or the Private Investigator and Security Guard Licensing Board, any files, documents, records or other information pertaining to the undersigned requested by the agency or board, or any of their authorized representatives, in connection with processing my application for licensure. I hereby release the aforementioned persons, firms, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Indiana Professional Licensing Agency, or the Private Investigator and Security Guard Licensing Board, to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information, which is material to my application, and I hereby specifically release the agency and the board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date of signature (month, day, year)

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