Fillable APPLICATION FOR PRIVATE DETECTIVE LICENSE (New Jersey State Police)

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APPLICATION FOR PRIVATE DETECTIVE LICENSE (New Jersey State Police)

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The APPLICATION FOR PRIVATE DETECTIVE LICENSE (New Jersey State Police) form is 8 pages long and contains:

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1
STATE OF NEW JERSEY
DIVISION OF STATE POLICE
APPLICATION FOR PRIVATE DETECTIVE LICENSE
MAIL ALL DOCUMENTS TO:
NEW JERSEY STATE POLICE
PRIVATE DETECTIVE UNIT
P.O. BOX 7068
WEST TRENTON, NEW JERSEY 08628
All license Qualifiers, Corporate Officers, Partners or LLC Members shall complete an application.
Provide all information requested within this application and any other attached forms.
The application shall be completed personally by the applicant.
Any omission or misstatement of fact is grounds for DENIAL - NJAC 13:55-1.11.
Any person who shall knowingly state any fact falsely shall be guilty or a misdemeanor - NJS 45:19-11.
No holder of a license issued under the Act may be a party to a franchise agreement nor accept money or other thing of value
for the right to act as agent of the licensee in accordance with New Jersey Administrative Code 13:55-1.7.
SP-171 (Rev. 03/14)
NAME (Print — Last) (First) (Middle)
Home Address (Street or R.D. Number) (City)
COUNTY
ZIP CODE
STATE
NAME OF AGENCY and/or TRADE NAME
(Number) (Street or R.D. Number) (City)
COUNTY
ZIP CODE
STATE
HOME PHONE NUMBER
AGENCY PHONE NUMBER
(Area Code/Number) E-mail
(Area Code/Number) E-mail
PRESENT OR
PROPOSED
ADDRESS OF AGENCY
CASE FILE NUMBER
(Number) (Street or R.D. Number) (City)
COUNTY
ZIP CODE
STATE
MAILING
ADDRESS
IF DIFFERENT
CLEAR FORM
2
Individual License Qualifiers*
CHECK THE APPROPRIATE BOX FOR THE LICENSE TYPE OR POSITION
*The Qualifier is that person who has 5 years' experience as an investigator or a police officer.
Corporate License Qualifiers*
Corporate License Officer
LLC License Qualifiers*
LLC License Member
Partnership License Qualifiers*
Partnership License Non-Qualifiers*
Name
All Corporate, LLC, and Partnership applications shall be submitted together as one entity.
List the name and address of all Corporate Officers, LLC members, or Partners
Address
NAME OR TRADE NAME
New Jersey Administration Code 13:55-1.6 - Advertising
No licensee shall conduct business under a name or trade name unless authorization has been obtained from the Superintendent of the New Jersey
State Police. The Superintendent shall not authorize the use of a trade name which, in his opinion, is so similar to that of a public officer or agency,
or that used by another licensee, that the public may be confused or misled thereby. The authorization shall require the filling of a trade name with
the County Clerk for an Individual or Partnership license or with the Department of Treasury, Commercial Recording and Business Services for a
Corporation or LLC license.
Use of a name different from an individual's name shall require filling with the County Clerk
Out of State Corporations or LLC's shall file with the Department of Treasury
SELECT TWO NAMES
1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3
PHOTOGRAPH
ATTACH CURRENT
FULL FACE PHOTO
No exposure below shoulders
NAME Last First MI
SOCIAL SECURITY NUMBER
DATE OF BIRTH
HEIGHT
HAIR COLOREYE COLOR
WEIGHT
RACE
Have you ever held or applied for a Private Detective License in this or any other State?
If Yes, state full details.
Have you ever been DENIED, or had a Private Detective License REVOKED or SUSPENDED in this or
any other State? If Yes, state full details.
Have you ever attended, been treated or observed by any doctor or psychiatrist, or at any hospital or mental
institution on an inpatient or outpatient basis for any mental or psychiatric condition? If Yes, state full details.
(Give the name and location of the doctor, psychiatrist, hospital or institution and the dates of occurrence.)
YES NO
YES NO
YES NO
YES NO
Have you been CONVICTED of any Disorderly Persons Offenses or any Criminal Laws of this State or any
other jurisdiction? If Yes, state full details. (Offense, Date, Location)
UTILIZE THE CONTINUATION PAGE FOR ADDITIONAL DETAILS TO ANY QUESTION
PLACE OF BIRTH COUNTRY OF CITIZENSHIP
4
EMPLOYMENT
List All Police or Investigative Employment (Past & Present)
TO BE COMPLETED BY APPLICANT'S EMPLOYER
EMPLOYING AGENCY
DATE EMPLOYED FROM - Month/Year TO - Month/Year
SUPERVISOR NAME/TITLE
APPLICANT - POSITION/TITLE
ADDRESS
TELEPHONE/E-MAIL
SUPERVISOR SIGNATURE
REASON FOR TERMINATION OF EMPLOYMENT
EXPLANATION OF APPLICANT'S DUTIES/GENERAL COMMENTS
EMPLOYING AGENCY
DATE EMPLOYED FROM - Month/Year TO - Month/Year
SUPERVISOR NAME/TITLE
APPLICANT - POSITION/TITLE
ADDRESS
TELEPHONE/E-MAIL
SUPERVISOR SIGNATURE
REASON FOR TERMINATION OF EMPLOYMENT
EXPLANATION OF APPLICANT'S DUTIES/GENERAL COMMENTS
UTILIZE THE CONTINUATION PAGE FOR ADDITIONAL SPACE
TO BE COMPLETED BY APPLICANT'S EMPLOYER
* Employer's letterhead stationary, providing the same information, may substitute for this form*
5
REFERENCES
The applicant shall insure that five reputable citizens, unrelated to the applicant and over the age of 21,
complete the following information and provide a signature attesting to the approval of the applicant.
A reference shall only complete and sign if offering approval of the applicant's character and competency
to be licensed as a New Jersey Private Detective.
HOME PHONE1. PRINT NAME
WORK PHONE
ADDRESS
E-MAIL
SIGNATURE
DATE
HOME PHONE2. PRINT NAME
WORK PHONE
ADDRESS
E-MAIL
SIGNATURE
DATE
HOME PHONE3. PRINT NAME
WORK PHONE
ADDRESS
E-MAIL
SIGNATURE
DATE
HOME PHONE4. PRINT NAME
WORK PHONE
ADDRESS
E-MAIL
SIGNATURE
DATE
HOME PHONE5. PRINT NAME
WORK PHONE
ADDRESS
E-MAIL
SIGNATURE
DATE
6
AUTHORIZATION FOR RELEASE OF INFORMATION
TO WHOM IT MAY CONCERN:
I, ____________________________________, AM HAVING A CONFIDENTIAL BACKGROUND
INVESTIGATION CONDUCTED ON ME BY THE NEW JERSEY STATE POLICE.
THEREFORE, I AUTHORIZE A REVIEW, FULL DISCLOSURE, AND RELEASE OF ALL RECORDS OR
INFORMATION, OR ANY PART THEREOF, CONCERNING MYSELF TO ANY SWORN MEMBER OF
THE NEW JERSEY STATE POLICE, WHETHER THE SAID RECORDS OR INFORMATION ARE PUBLIC
OR PRIVATE, AND INCLUSIVE OF RECORDS OR INFORMATION CONSIDERED PRIVILEGED OR
CONFIDENTIAL IN NATURE.
THE RELEASE AUTHORIZATION IS INTENDED TO PROVIDE A RELEASE OF ANY INFORMATION
THAT CAN BE UTILIZED AS INVESTIGATIVE RESOURCE MATERIAL DURING THE BACKGROUND
INVESTIGATION FOR A NEW JERSEY PRIVATE DETECTIVE LICENSE, AND DURING AN
INDIVIDUAL'S ENTIRE LICENSE PERIOD. THE RELEASE WILL REMAIN IN EFFECT DURING THE
INITIAL LICENSE PERIOD AND SUBSEQUENT LICENSE RENEWAL PERIODS.
A PHOTOSTATIC COPY OF THIS AUTHORIZATION WILL BE CONSIDERED AS EFFECTIVE AND
VALID AS THE ORIGINAL.
SIGNATURE MUST BE NOTARIZED
I,________________________________________________________ AFFIRM THAT I AM THE ABOVE
NAMED PERSON MAKING APPLICATION FOR A NEW JERSEY PRIVATE DETECTIVE LICENSE.
I READ AND ANSWERED EACH QUESTION WITHIN THE APPLICATION COMPLETELY AND
TRUTHFULLY.
_________________________________________________
APPLICANT SIGNATURE DATE
Sworn to before me this
___________________________ day of ________________________, _________
_________________________________________________
Notary Public
YEAR
PRINT NAME
PRINT NAME
7
CONTINUATION PAGE
8
STATE POLICE USE ONLY
RECORD SEARCH REPORT
PROMIS GAVEL
AUTOMATED COURT SYSTEM
PRIVATE DETECTIVE UNIT
AFFIRM
N.C.I.C./S.C.I.C
MOTOR VEHICLE
FEDERAL PRINT
STATE PRINT
CREDIT
PRIVATE DETECTIVE UNIT
DATE
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APPLICATION FOR PRIVATE DETECTIVE LICENSE (New Jersey State Police)

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Completed 6 November 2020

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