• ___ Employee of licensed private detective agency
• ___ Independent private detective
• ___ Officer, director, partner or associate of licensed private detective agency

• 1. Name of person:
  
• 2. Residence Address:
  
• 3. Residence phone:
  
• 4. Business phone:
  
• 5. Fax number:
  
• 6.
  • If an employee of a licensed private detective agency, name and address of agency:
    

    
    

  • If an independent private detective, name and address of business:
    

    
    

  • If you are an officer, director, partner or associate of a licensed private detective agency and engage in detective business, name and address of agency:
    

    
    

• 7. Mailing address if different from above:
  

• 8. In the past 2 years, to your knowledge, have you:
  
  • (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 as a private detective denied, suspended, revoked or subjected to disciplinary action 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.

______________________________
Renewal Applicant's Signature

I, ________________________, applicant for renewal of a private detective license submit that I am presently employed by a private detective agency, ____________________, licensed by the state of Kansas under agency license number ____.

______________________________
Renewal Applicant's Signature

_______________________________
Employer's Signature

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