Agency Use Only:
Date Received at KBI:

• 1.Name of applicant:           (Type or Print Full Name)
     Maiden or any alias names used:
  
• 2. If you intend to engage in detective business as an employee of a private detective agency or as a independent private detective, complete this section:
  "Independent private detective" means a person who engages in detective business, but who is not employed by a licensed private detective agency and does not regularly employ any other person to engage in detective business.
  
  • (a) Check one:      Employee      Independent
    
  • (b) Name of employing agency or name under which you intend to engage in detective business:
    
  • (c) Street address of agency or place of business:
    
  • (d) Mailing address if different:
    
  • (e) Telephone number:               Fax number
    
  • (f) If you will be employed by a private detective agency, you and your employer must sign a Statement of Employment (page 6 of application).
  
  
• 3. If you intend to engage in detective business as a partner, officer, director or associate of a private detective agency, complete this section:
  • (a) Name of agency:
    
  • (b) Position with agency: Owner   Associate   Partner   Officer   Director
    
  • (c) Street address:
    
  • (d) Mailing address if different:
    
  • (e) Telephone number:
    
  • (f) Fax number:
    [end page 1]
  • 4.
    • Sex   Race      Date and Place of Birth
      
    •      Height    Weight    Hair      Eyes
      
    • D.L.#        State:
      
    • Social Security #
      Providing your Social Security Number is voluntary, but it is requested pursuant to K.S.A. 74-139 so that, if requested, it may be provided to the Director of Taxation)
      
    • Are you a citizen of the United States?   Yes   No   Of what state are you currently a resident?
    
    If naturalized, attach documentation.

  • 5. Provide a statement of the general nature of the kind of private detective business in which you intend to engage:

  • 6. Have you graduated from high school or earned a Graduate Equivalency Degree (GED)? Where? When? Attach a copy of diploma, certificate or other verification.

  • 7. IF THE ANSWER TO ANY OF THE FOLLOWING QUESTIONS IS ‘YES', PLEASE PROVIDE FULL INFORMATION IN THE "DETAILS" SECTION.
    
    
    • (a) Are you currently a law enforcement officer with any law enforcement agency of the federal government or of the state or any political subdivision thereof Yes No
      
    • (b) Do you currently hold a special commission from any law enforcement agency of the federal government or of the state or any political subdivision thereof.? Yes- No
      "Special Commission 'refers to any type of identification issued by a law enforcement agency or law enforcement officer which grants any temporary or permanent law enforcement authority to make arrests or maintain the public peace.
      
    • (c) Within the past year have you been found incompetent, incapacitated or impaired by reason of mental condition, deficiency or disease? Yes- No
      
    • (d) Are you currently addicted to, dependent on or abusive of alcohol or any controlled substance, narcotic or drug excluding medication prescribed by a physician? Yes- No
      
    • (e) Are you receiving inpatient or outpatient treatment for alcohol, any controlled substance, narcotic or drug addiction, dependence or abuse? Yes- No
      
    • (f) Have you received such treatment within the past year? Yes No
      [end page 2]
    • (g) In the past ten years have you been convicted of a felony or any crime (including any DUI) other than minor traffic violations in this state or any other state? Yes- No
      If "yes" provide circumstances of the offense, title of court (municipal, state or federal) original charge(s), whether convicted by trial or plea, charges convicted of, whether sentence was imprisonment, probation or other disposition. Also, give your reasoning why the conviction(s) should not preclude you from being licensed as a private detective.
      
    • (h) If you were in military service, branch and services serial number:
      
    • (i) Were you dishonorably discharged? Yes   No
      
    • (j) Have you ever been denied a private detective license from another state? What state? When?
      Yes   No
      
    • (k) Have you ever been or are you presently licensed as a private detective in another state?  Yes   No
      What state?      When were you licensed?    Has that license ever been suspended, revoked or subjected to other disciplinary action?  Yes   No
      
    • (1) Have you ever been an officer, director, partner or associate of a person or agency which has been refused a private detective license or had a private detective license suspended, revoked or subjected to other disciplinary action in this state or any other state? Yes- No
      
    • (m) To your knowledge have you ever been the subject of a complaint to any department, bureau, board or any other governmental or regulatory body in this state or any other state?  Yes   No
      DETAILS (use reverse side of page if necessary):
    [end page 3]
  • 8. EMPLOYMENT: List ALL previous employers (including U. S. military service in reverse chronological order. (Use back of page if necessary)
    • (a) EMPLOYER:
      Employer's address:
      Occupation               Dates of Employment
      Reason for Leaving:

    • (a) EMPLOYER:
      Employer's address:
      Occupation               Dates of Employment
      Reason for Leaving:

    • (b) EMPLOYER:
      Employer's address:
      Occupation               Dates of Employment
      Reason for Leaving:

    • (c) EMPLOYER:
      Employer's address:
      Occupation               Dates of Employment
      Reason for Leaving:

    • (d) EMPLOYER:
      Employer's address:
      Occupation               Dates of Employment
      Reason for Leaving:

    • (e) EMPLOYER:
      Employer's address:
      Occupation               Dates of Employment
      Reason for Leaving:
      [end page 4]
  • RESIDENCE ADDRESSES: List ALL previous addresses for the last ten years in reverse chronological order. Use month and year for date information. usee back of page if necessary)
    • (a) Current: Dates      Address:
      (Number of Street)
      
      City                State     (zip)
      
    • (b) Dates:      Address:
      (Number of Street)
      
      City                State     (zip)
      
    • (c) Dates:      Address:
      (Number of Street)
      
      City                State     (zip)
      
    • (d) Dates:      Address:
      (Number of Street)
      
      City                State     (zip)
      
    • (e) Dates:      Address:
      (Number of Street)
      
      City                State     (zip)
      
    • (f) Dates:      Address:
      (Number of Street)
      
      City                State     (zip)
      
    • (g)Dates:      Address:
      (Number of Street)
      
      City                State     (zip)
      
    • (h) Dates:      Address:
      (Number of Street)
      
      City                State     (zip)
      
    [end page 5]
    
  APPLICANT'S AFFIDAVIT
  (MUST BE SIGNED BEFORE A NOTARY PUBLIC)
  

  I,               , of lawful age, being first duly sworn, on my oath, state that I am the applicant herein and that I have read and examined the statements made in the above and foregoing application, including all statements made in any accompanying papers, and that the information contained herein is true and correct to the best of my knowledge and belief
  

  
  Applicant Signature
  

  Subscribed and sworn to before me this     day of       , 1999
  

  Notary
  My commission expires:
  
  STATEMENT OF EMPLOYMENT (ONLY FOR APPLICANTS EMPLOYED BY AN AGENCY)
  

  I,                , applicant for a private detective license, submit that I am presently or will be employed upon being issued a private detective license, by a private detective agency, licensed by the State of Kansas under agency license number       .
  

  
  Applicant Signature
  
  Employer Signature
  [end page 6] AFFIDAVIT
  CERTIFICATE OF REFERENCE
  

  Regarding the application of
  

  I,
  

  of
       (Include full business name, address and telephone number)

  and
       (include full residence address and telephone number)
  

  subscribe and affirm that:
  

  
  
  
  • I am a reputable person and a citizen of the United States.
    
    
  • I have personally known the applicant for a period of at least five (5) years past and I am not related or connected by blood or marriage to the applicant.
    
    
  • I have read his/her application for a license as a private detective and believe each of the statements made therein to be true and correct to the best of my knowledge and belief
    
    
  • The applicant is a person of good moral character and he/she is honest and competent to engage in the business as a private detective.
    
    
  • I recommend that his/her application for a license as a private detective be granted.
    
  
  Reference/Affiant Signature
  
  VERIFICATION
  

  STATE OF
  

  COUNTY OF
  

  ________________________, of lawful age, being first duly sworn, upon his/her oath, subscribes and affirms:
  That he/she is the reference named in the above-captioned Certificate of Reference; that he/she has read the above and foregoing Certificate of Reference, knows and understands the contents thereof, and states that the statements contained therein are true and correct, according to his/her knowledge, information and belief

  Reference/Affiant Signature

  
  

  SUBSCRIBED AND SWORN TO before me, the undersigned authority on this ____ day of __________, 19
  

  Notary Public

  
  [Seal]
  
  My Appointment expires
  [end page 7]
  SPECIAL COMMISSION STATEMENT I, ______________________, understand that K. S.A. 75-7b02(c) provides that unless expressly exempted from the provisions of the Kansas Private Detective or Security Operations Act, no law enforcement officer, or any person who holds a special commission from any law enforcement agency of the federal government or of the state, or any political subdivision thereof, may be licensed as a private detective or private detective agency. I further understand that special commission refers to any type of identification issued by a law enforcement agency or law enforcement officer which grants, or appears to grant, any temporary or permanent law enforcement authority, including but not limited to deputy, special deputy, special assistant, reserve officer, special officer or honorary officer.
  
  
  Signature
  
  Date