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F:\ADMIN\USERS\Kay\Security Guard Info\Security Guard App '10.doc APPLICATION FOR REGISTRANT Under the Private Investigator and Patrol Operators Ordinance INCORRECT RESPONSES ON THIS FORM MAY RESULT IN DENIAL OF YOUR APPLICATION ATTENTION! Incorrect or false information on this form may result in DENIAL of your application. It is not what you did or may have done that causes most denials. The cause is usually from answering questions incompletely, incorrectly or falsely. If you have any doubt about your past history, it is highly recommended, before you fill out your application, that you request copies of your traffic violation records and any other criminal records from City, County, State or Federal law enforcement organizations. By my initials hereafter, I state that I have read and understand the above paragraph. (Applicant's initials) 1. Date of application: 20 2. Name of applicant: 3. Name of Sponsor/Licensee (Employer): 4. Address of Sponsor/Licensee (Employer): 5. Classification of Sponsor/Licensee: Private Patrol Operator Private Investigator Both 6. Applicant’s date of birth: 7. Applicant’s present address: 8. Applicant’s Social Security 9. Please list all residences the applicant has had for the past 10 years in chronological order. Address Dates ---PAGE BREAK--- 2 Revised 9/2010 10. State all occupations the applicant has had during the last 10 years in chronological order. Occupation: Name of Supervisor: Employer: Dates of Employment: Address of Employer: Occupation: Name of Supervisor: Employer: Dates of Employment: Address of Employer: Occupation: Name of Supervisor: Employer: Dates of Employment: Address of Employer: Occupation: Name of Supervisor: Employer: Dates of Employment: Address of Employer: Occupation: Name of Supervisor: Employer: Dates of Employment: Address of Employer: 11. Attached is a full set of classifiable fingerprints and one photograph of the applicant taken within the past 6 months. 12. A brief outline of applicant’s background as a private patrol operator or private investigator is as follows: I have worked in a related field for a period of years. ---PAGE BREAK--- 3 Revised 9/2010 13. Has the applicant as an adult or juvenile, EVER been arrested or detained relating to any criminal offense (non-traffic), regardless of court disposition, dismissal or plea agreement? Yes No If yes, describe, listing dates, locations and offenses. 14. Has the applicant, as an adult or juvenile, EVER been convicted of any criminal offense (excluding minor traffic violations), regardless of sentence or other disposition? Yes No If yes, describe, listing dates, locations and offenses. 15. Has the applicant EVER been refused a license as a private investigator or private patrol operator or has the applicant had such a license revoked or suspended for cause? Yes No If yes, describe, listing dates, locations and offenses. 16. Is the applicant presently licensed as a private investigator or private patrol operator under the Private Investigators Act of the State of New Mexico? Yes No If yes, give NM State Private Patrol Operator or NM State Private Investigator license number: FOR ASSISTANCE IN COMPILING YOUR CRIMINAL AND/OR TRAFFIC OFFENSE HISTORY, CONTACT LAW ENFORCEMENT AGENCIES AND COURTS WITH WHICH YOU HAVE HAD PREVIOUS CONTACT. ---PAGE BREAK--- 4 Revised 9/2010 STATE OF NEW MEXICO ) COUNTY OF SAN JUAN ) ss. CITY OF FARMINGTON ) The information contained in this application is true and complete to the best of my knowledge. Signature of Applicant Acknowledged before me this day of 20 Notary Public My Commission Expires: OFFICIAL USE ONLY The Farmington Police Department has completed an investigation of the applicant and the above application is approved and a license should be issued in the name of the applicant. denied for the following reason(s): Date Chief of Police or Designee FOR DENIALS ONLY Letter of denial sent: Last date to appeal: Appeal received? Yes No Date received: Appeal Hearing date: City Council approved ____/denied____ City Clerk ---PAGE BREAK--- 5 Revised 9/2010 AFFIDAVIT STATE OF NEW MEXICO ) COUNTY OF SAN JUAN ) ss. CITY OF FARMINGTON ) I, being first duly sworn upon oath, state: I have made application under Chapter 8, Article 9 as a Licensee or Registrant in the City of Farmington, New Mexico and I understand that: this necessitates a background check on me; any false information provided by me on this application is grounds for denial of the City of Farmington private patrol operator/investigator license; and I hereby give my consent to the City of Farmington to conduct such a check and appoint the City as my representative to have access to any and all information concerning me, including arrest record information. Further, affiant states not. Signature Street Address City, State, Zip Code Acknowledged before me this day of Notary Public My Commission Expires: