• 1. Name of person:
  submitting renewal (Type or print full name)
• 2. Agency Name:
  
• 3. Address of principal place of business:

  
  (number & street) (City) (County) (State) (Zip)

• 4. Mailing Address if different from business address:

  
  

• 5. If application is also for a branch office or sub-agency, business address of same:

  
  (number & street) (City) (County) (State) (Zip)

  Business phone number:
  Fax number:

• 6. If any change has occurred regarding the name, residence address or capacity of any of the agency's partners, officers, directors or associates, please indicate change below:
  
  • (a) Name
    Position
    U.S. Citizen
    Residence Address
    Date of Birth
    SSN#
    DL#
    
    
  • (b) Name
    Position
    U.S. Citizen
    Residence Address
    Date of Birth
    SSN#
    DL#
    
  
  
• 7. In the past year, to your knowledge, has any officer, partner, associate or director of the agency:
  
  • (a) been the subject of a complaint to any department, bureau, board, prosecuting officer, criminal court, or any other governmental or regulatory body or officer in this state or elsewhere? ___Yes ___No
    
  • (b) had any license or permit suspended, revoked or denied in this state or elsewhere? ___Yes ___No
    
  • (c) been arrested, indicted or convicted of a felony or any crime other than minor traffic violations in this state or any other state? ___Yes ___No
    
  • (d) become a law enforcement officer or been granted a special commission from any law enforcement agency? ___Yes ___No
    
  • (e) been found incompetent, incapacitated or impaired by reason of mental condition, deficiency or disease? ___Yes ___No
    
  • (f) become addicted to, dependent on or abusive of alcohol or any controlled substance, narcotic or drugs? ___Yes ___No
    
  • (g) received inpatient or outpatient treatment for alcohol, any controlled substance, narcotic or drug addiction, dependence or abuse? ___Yes ___No
    
  
  

I, ________________________, of lawful age, being first duly sworn, on my oath state that I am authorized by the ____________________ , Private Detective Agency, to sign the renewal application, and that I have read and examined the statements, made in the above and foregoing application, and that the information contained herein is true and correct to the best of my knowledge and belief. I understand that as an operator of an agency I may only employ licensed private detectives to engage in investigative activities, such as surveillance, interviews, and background investigations.

__________________________
Signature - Position

Subscribed and sworn to before me, a Notary Public, in and for ________________________ County, State of ____________________, this ______ day of _______________, 199 __.
My commission expires: _________________________