Free application form - West Virginia

STATE OF WEST VIRGINIA SECRETARY OF STATE BLDG. 1, SUITE 157K 1900 KANAWHA BLVD. EAST CHARLESTON , WV 25305

APPLICATION FOR PRIVATE INVESTIGATOR LICENSE
PLEASE READ CAREFULLY false, incomplete or inaccurate answers will lead to automatic refusal of this application. 1. L as t N a me 4. Address 5. Mailing Address 6. County 9. Birthdate 13. Name of Spouse 15. US Citizen 16. W V Res ident 10. Place of Birth 7. Phone Number 11. Male/ Fem ale 14. Occupation/Employment of Spouse # of years 17. Heig ht 18. W eight City State 8. Social Security Number 12. Single/Married/Widowed/Divorced Zip City State Zip First Midd le 2. M a id en N am e 3. N ic k na m e

19. Eye Color

20. State of driver's license

21. License Num ber

22. List identifying scars, marks or tattoos

23.

Yes No 24. Branch Military Service 28. Type of Discharge

25. Rank

26. Dates

27.

If dish ono rable , plea se ex plain 30.

29. Business Name 31. Business Address 32. City Coun ty

Business Phone

State

Zip

Are you or have you ever been addicted to the immoderate use of alcohol and/or drugs or treated for an alcohol or drug related illness?

33.

Have you ever been a patient in a public or private mental hospital? If so, pleas e list

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34.

Have you ever been discharged, suspended or forced to resign from any position? If yes, give name and address of the employer, date of the discharge or forced resignation and the reason

35.

Have you ever been denied a private investigator's license or any other professional certification? If yes, give complete details

36.

Have you ever had a private investigator's license suspended or revoked or any other professional certification? If yes, give complete details

37.

Have you ever been affiliated with an agency that operated without a valid license or whose license has been suspended or revoked? If yes, give the name and address of the agency, the dates of

ope ration , sus pen sion or rev oca tion, a nd you r relat ions hip to the a gen cy

38. 39.

Have you ever applied for and/or received a license elsewhere? EDU CAT ION: If your qualifications are based on studies in investigative work at an accredited college or university you MUST enclose a copy of your transcript with the application.

High Sch ool GED College Total Semester Hours in Investigative Studies Degree Received Additional Training If yes, year completed

Grade Completed

Years Attended

Years attended Major

Total Semester Hours Minor

40.

List all jobs you have held. Put your present or most recent job first. If you need more space, you may attach additional sheets. Include military service and temporary part-time jobs.

A.

Name of employer Address of em ployer

Type of business

2

Name and title of supervisor Position(s) held Began B. Left Full-time/Part-time Hours worked per week Type of business

Name of employer Address of em ployer Name and title of supervisor Position(s) held Began Left Full-time/Part-time

Hours worked per week Type of business

C.

Name of employer Address of em ployer Name and title of supervisor Position(s) held Began Left Full-time/Part-time

Hours worked per week Type of business

D.

Name of employer Address of em ployer Name and title of supervisor Position(s) held Began Left Full-time/Part-time

Hours worked per week Type of business

E.

Name of employer Address of em ployer Name and title of supervisor Position(s) held Began Left Full-time/Part-time

Hours worked per week

41.

If eligibility for private investigator's license is based upon prior investigative experience list the details of such

employment experience

42.

Have yo u ever be en cha rged, indic ted, arres ted or co nvicted o f any crim inal offens es of an y nature: (F ailure to answer this question fully and correctly will result in denial of your application)

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43.

Have you ever been known by another name?

If yes, list all such names and spelling variations

44.

Please list all addresses used in the last ten (10) years

YOU MUST INCLUDE THE FOLLOWING DOCUMENTATION WITH THE COMPLETE NOTARIZED APPLICATION:

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Charac ter reference s from fiv e (5) reputa ble citizens w ho hav e know n you for a t least five (5) yea rs preceding the application and fo r the purpose o f this application (form en closed). Two (2) passport size photos taken within one year of the date of the application. Fingerprints of all fingers of both hands on State Police Fingerprint Cards. Correct application fee. West Virginia Resident Application: Individual - $150, Firm - $250. Non-Resident Application: Individual - $550, Firm $550. ***NOTE: FEE INCLUDES A NON REFUNDABLE APPLICATION PROCESSING FEE of $50, REMAINING FEE IS REFUNDED IF APPLICATION IS DENIED. A completed surety bond, by an approved insurance com pany, in the am ount of $2,500 (form enclosed). Supporting documentation of qualifications, education or employment for private investigations.

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OATH OR AFFIRMATION State of , County of .

I, , understand that an investigation may be made whereby information is obtained regarding my character, previous employment, general reputation, educational background, credit record and criminal history. I hereby authorize anyone possessing this information to furnish it to the Secretary of State and any authorized representative of the Secretary of State. I release the Secretary of State and any authorized representative from all liability and damages whatsoever in furnishing, obtaining or using said information. Further, I hereby certify that all answers and statements given herein are true and correct without reservation of any kind.

Signature of Applicant

Subscribed and sworn before me this My Commission expires on

day of .

,

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Signa ture of N otary Pu blic (Nota ry Seal)

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CERTIFICATION OF CHILD SUPPORT OBLIGATIONS FORM
****PLEASE COMPLETE AND RETURN WITH YOUR APPLICATION**** (Please print or type) 1. Applicant's Name: Last: First: Middle: 2. Applicant's Address: Street: City: County: State/Zip: 3. Telephone: 4. Social Security Number: 5. If a firm please complete the following information: Firm Name: Firm Address:

Firm Telephone:

Pursuant to WV Code §48A-5A-5(c) each applicant for license must answer the following questions and certify, under penalty of false swearing, that these answers are true and correct. Please answer yes or no to the following questions: 1. Do you have a child support obligation? 2. If the answer to question 1, above, is yes, are you in arrearage? 3. If the answer to question 2, above, is yes, does your arrearage equal or exceed the amount of child support payable for six (6) months? 4. Are you the subject of a child support related subpoena or warrant? Yes Yes Yes Yes No No No No

do hereby certify, under penalties of perjury and false swearing, I, that the above information is true and correct to the best of my knowledge. I understand that if I make a false statement concerning any question on this application, I may be subject to disciplinary action including, but not limited to, immediate revocation or suspension of my private investigator and/or security guard license.

Signature of Applicant

CHARACTER REFERENCE LETTER FOR THE FOLLOWING APPLICANT: _______________________________________________________ CHARACTER REFERENCE INFORMATION
Name: _____________________________________ Address: ___________________________________ City, State Zip: ______________________________ Phone: _____________________________________ Length of time that reference has known applicant : ______________________________

COMMENTS:

I, hereby certify that all the comments given herein are true and complete without reservations of any kind, I, also hereby certify that I have known the applicant filing for a private investigator and/or security guard for at least five years and that I am not related to the applicant by blood or marriage. _____________________________________ Signature ________________________ Date

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