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APPLICATION FOR SECURITY ALARM SYSTEM ... - …

CSCL/LSA-010 (8/15) Page 2 QUALIFYING EXPERIENCE INFORMATION If you are applying for private security guard agency license, you must meet one …

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Text of APPLICATION FOR SECURITY ALARM SYSTEM ... - …

FOR OFFICE USE ONLYFEE PAYMENT INFORMATION (Check One Box)CSCL/LSA-010 (8/15)Page 1Michigan Department of Licensing and Regulatory Affairs Corporations, Securities & Commercial Licensing Bureau Schools and Licensing Box 30018, Lansing, MI your check or money order in Currency payable to:STATE OF MICHIGANFEES ARE AUTHORIZED UNDER 1968 PA 330LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals AddressCityStateZip CodeCompany NameTelephone NumberE-mail AddressAPPLICATION FOR SECURITY ALARM SYSTEM CONTRACTOR ORSECURITY GUARD AGENCY LICENSE OR RELICENSUREAUTHORITY: 1968 PA 330, MCL (A), AND 42 USC 654PENALTY: FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN DENIAL OF THE APPLICATIONAND/OR DISCIPLINARY ID# (if applicable)$ License3801-01$ License (Sole Proprietor)3801-01Security Guard AgencySecurity Guard Agency Relicensure$ License (Sole Proprietor)$ License3801-06FOR OFFICE USE ONLY - VALIDATIONHave you ever been adjudged insane?YesNoIf yes, have you been restored to sanity by court order?YesNoDo you have any outstanding warrants for your arrest?YesNoHave you ever been convicted of a felony not previously reported to the Department for this license type or occupation?NoYesHave you ever been convicted of a misdemeanor within 5 years involving any of the following before the date of this application?(dishonesty or fraud, unauthorized divulging or selling of information or evidence, impersonation of a law enforcement officer or employee ofthe United States, this state or a political subdivision of this state, illegally using, carrying, or possessing a dangerous weapon, two or morealcohol related offenses, controlled substances under the public health code, 1978 PA 368, MCL to or you have a high school diploma or its equivalent?NoYesDid you serve in the armed forces and act as a military police officer or in an equivalent job classification for at least 2 years?NoYesName (First, Middle, Last)US Social Security NumberDate of BirthFOR OFFICE USE ONLYApproved By:Date Approved:License Number$ Alarm System ContractorFee WaivedNew Individual Applicant - Veteran(see required additional documentation)Fee WaivedNew Individual Applicant - Veteran(see required additional documentation)$ Alarm System ContractorRelicensureCSCL/LSA-010 (8/15) Page 2QUALIFYING EXPERIENCE INFORMATIONIf you are applying for private security guard agency license, you must meet one of the following: (check all that apply)(i) Was engaged in the private security guard or agency business on his or her own account in another state for a period of at least 3 years.(ii) Was engaged in the private security guard oragency business for a period of at least 4 years as an employee of the holder of a certificate ofauthority to conduct a private security guard or agency business and has experience reasonably equivalent to at least 4 years of full-time guard work in a supervisory capacity with rank above that of patrolman.(iii) Was employed in law enforcement as a certified police officer on a full-time basis for at least 4 years for a city, county, or state government or forthe United States government.(iv) Was engaged in the private security guard or agency business as an employee or on his or her own account or as a security administrator inprivate business for at least 2 years on a full-time basis, and is a graduate with a baccalaureate degree or its equivalent in the field of police administration or industrial security from an accredited college or university.(v) While on active duty as a member of the armed forces, served as a military police officer or in an equivalent job classification for at least 2 years;was honorable character of service or under honorable conditions (general) character of service from that military service; and provides with his or her application an affidavit signed by a commanding officer, supervisor, or military superior with direct knowledge of the applicant's service that he or she has, entry-level experience in or basic knowledge of each of the following:(A) Enforcing rules, regulations, and guidelines.(B) Providing security and physical protection.(C) Area and site security operations.(D) Overseeing prisoners and correctional facilities(E) Reconnaissance and you are applying for a security alarm system contractor license, you must have been lawfully engaged in either or both of the following: (check all thatapply)A security alarm system contractor business on his or her own account for a period of not less than 3 security alarm system contractor business for a period of not less than 4 years as an employee of the holder of a certificate of authority to conduct asecurity alarm system contractor business, and have experience reasonably equivalent to at least 4 years of full-time work in a supervisory do not have experience equivalent to at least 4 years of full-time work in a supervisory capacity. (The Department will notify you authorizing you toto take the exam).Additional Required DocumentsCertification:SignatureDateCity Print NameAPPROVAL COUNTY SHERIFF OR CITY CHIEF OF POLICE WHERE PRINCIPAL OFFICE LOCATED - Required per MCL (3)SignatureDateTitle (Sheriff or City Chief of Police)CountyAPPROVAL COUNTY PROSECUTING ATTORNEY WHERE PRINCIPAL OFFICE LOCATED - Required per MCL (3)CityPrint NameSignatureDateCountyTitleI certify that the statements in this document are true and complete. I understand that any omitted statement, misrepresentation, or fraud may be cause fordenial of my application, disciplinary action, or may be punishable by law. I agree the Department is required by law to obtain my social security numberpursuant to MCL (a). 5 reference statements pursuant to MCL (1) 2 passport quality photos of individual or of the resident manager if a business pursuant to MCL (2) Surety bond or certificate of insurance pursuant to MCL (1) Certificate of incorporation of business, if applicable If requesting a fee waiver as an individual who served in the armed forces - form DD214, DD215, or any other form acceptable to the Department thatdemonstrates you were separated from service with an honorable character of service or under honorable conditions (general) character of service. If you are using your experience in the military as qualification for licensure, you must also submit the documentation listed above along with an affidavitsigned by a commanding officer, supervisor or military superior with direct knowledge of your service and that you have entry-level experience in or basicknowledge of each of the items listed in MCL (1)(g)(v).

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