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Burglar Alarm Company (Utah DRE)

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  • 26 check-boxes
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Utah Division of Real Estate (DRE) aims to protect the public and promote responsible business practices through education, licensure, and regulation of real estate, mortgage, and appraisal professionals

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State of Utah
Department of Commerce
Division of Occupational and Professional Licensing
DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
Burglar Alarm Company
APPLICANT INFORMATION
Business Legal Name:
*Note: If you are a Sole Proprietor, this is your legal name.
Utah Division of Corporation
Registration Number:
IRS Employee ID
Number (EIN):
DBA (if applicable):
DBA Registration
Number:
Mailing Address:
Street Address (including Apt/Unit/Ste #) and/or PO Box
City
State
ZIP Code
You will receive all Division notices and communications at the following email.
Email:
Email Address is Required.
Company Phone:
Local Contact for Licensing Purposes:
Alternate Phone for Local Contact:
I understand that in all areas of this application the words “you”, “I” and “applicant” apply to the entity listed above
and all subsidiaries, owners, qualifiers, and prior entities and DBA’s for which these individuals have been involved.
AFFIDAVIT AND RELEASE
1. I certify that I am qualified in all respects for the license for which I am applying in this application.
2. I certify that to the best of my knowledge, the information contained in the application and all supporting
document(s) are true and correct, discloses all material facts regarding the applicant, and that I will update or
correct the application as necessary, prior to any action on my application.
3. I authorize all persons, organizations, governmental agencies, or any others not specifically listed, which are set
forth directly or by reference in this application, to release to the Division of Occupational and Professional
Licensing, State of Utah, any files, records, or information of any type reasonably required for the Division to
properly evaluate my qualifications for licensure/certification/registration by the State of Utah.
4. I understand that it is the continuing responsibility of applicants and licensees to read, understand, and apply the
requirements contained in all statutes and rules pertaining to the occupation or profession for which I am applying,
and that failure to do so may result in civil, administrative, or criminal sanctions.
5. I certify that I do not currently pose a direct threat to myself, to my clients, or to the public health, safety or welfare
because of any circumstance or condition.
6. I understand that I am responsible to update the Division of any changes relating to my
license/certification/registration.
Signature of Authorized Signer:
Date:
Printed Name and Position of the Authorized Signer:
F-55dBAC-App
20210701
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DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
GENERAL BUSINESS INFORMATION
Section 1: Please select entity type:
Business Trust
Corporation
General Partnership
Limited Liability Company
Limited Partnership
Limited Liability Partnership
Sole Proprietorship
If registered as sole proprietorship,
complete Section 2 below.
Section 2: To be completed by Sole Proprietorship applicants only.
Full Legal Name:
First
Middle
Last
All Previous Legal Names:
Other DOPL Licenses Held:
SSN:
Date of Birth:
Gender: Male Female
Please Select ONE:
I am a United States citizen OR a non-citizen of the United States who is lawfully present.
I am a foreign national not physically present in the United States.
None of the above, please explain:
Driver License
or State Id Card:
State of Issue
License Number
Expiration Date
NOTE: If you do not hold a US Driver’s License or a US State ID, you must present a legible copy of your current and
valid government issued document(s) showing evidence of lawful presence in the United States.
PROFESSIONAL LICENSES
List all other licenses, registrations or certifications issued by any state which you now hold or have ever held in any
profession.
(Use additional sheets if necessary.)
Profession:
License Number:
Issuing State:
License Status:
Issue Date:
Profession:
License Number:
Issuing State:
License Status:
Issue Date:
F-55dBAC-Org
20210701
DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
QUALIFYING QUESTIONNAIRE
Do not leave any question blank.
DOPL may request additional documentation if the information submitted is insufficient.
1. Yes No
Have you EVER had a license, certificate, permit, or registration to practice a regulated
profession denied, conditioned, curtailed, limited, restricted, suspended, revoked,
reprimanded, resigned, or surrendered while under investigation, or otherwise disciplined
in any way?
2. Yes No
Do you CURRENTLY have any criminal action active or pending?
3. Yes No
WITHIN THE PAST 10 YEARS, have you pled guilty to, no contest to, entered into a
plea
in abeyance, or been convicted of a misdemeanor in any jurisdiction?
4. Yes No
Have you EVER pled guilty to, no contest to, entered into a plea in abeyance, or been
convicted of a
felony in any jurisdiction?
If you answered “Yes” to any of the above questions, enclose with this application complete information with respect to
all circumstances and the final result, if such has been reached. If you answered “Yes” to questions 2, 3, or 4 you must
submit the following for EACH and EVERY incident:
• personal account of the incident
• police report(s)
• court record(s)
• probation/parole officer report(s)
If you are unable to obtain any of the records required above, you must submit documentation on official letterhead from
the police department and/or court indicating that the information is no longer available.
NOTE:
DISCLOSE charges that were later held in abeyance, diverted, reduced, or dismissed.
DISCLOSE motor vehicle offenses such as driving while impaired or intoxicated. But you do not need to
disclose minor traffic offenses such as parking or speeding violations.
You do not need to disclose juvenile offenses, unless you were tried as an adult.
DISCLOSE if you are restricted from possession, purchase, transfer, or ownership of a firearm or
ammunition (even if your restriction is based on a non-reportable juvenile conviction).
You do not need to disclose legally expunged or sealed criminal history incidents.
For more information, see DOPL’s criminal history FAQs.
F-55dBAC-QQ
20210701
DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
PAYROLL & INSURANCE
The applicant HAS EMPLOYEES or OWNER-WORKERS and appropriate workers compensation insurance is
in force and will be maintained.
YOU MUST PROVIDE THE FOLLOWING:
1. A copy of your workers compensation certificate
AND
The following information:
• Department of Workforce Services Unemployment Insurance Registration Number: _______________
• State Tax Commission Withholding Tax Account Number: ___________________________________
• Federal (IRS) Employee Identification Number (EIN): _______________________________________
OR
2. A copy of your signed contract with a registered professional employment organization (PEO).
The applicant does NOT HAVE EMPLOYEES and does not intend to hire employees within the foreseeable
future.
GENERAL LIABILITY INSURANCE
All licensees MUST have a General Liability Insurance. The minimum required coverage is $300,000 for each
incident and $1,000,000 in total. The coverage must cover all scope of work for the licensee for the entire duration of
active licensure.
DO NOT INCLUDE YOUR INSURANCE CERTIFICATE WITH THIS APPLICATION. PLEASE RETAIN IT IN YOUR
OWN RECORDS. DOPL MAY REQUEST A COPY OF THE INSURANCE CERTIFICATE AT ANY TIME.
CERTIFICATION
I certify that the licensee has general liability insurance, as required by Utah law and rules, that covers all scope of work
of the licensee, and shall be in effect for the entire duration of active licensure.
I certify that I will maintain a copy of all general liability insurance certificates at all times of active licensure, that
includes the name and address of the insurance company, name and address of the insured, policy number, expiration
date, and policy limits.
I certify that if the licensee has employees or owner-workers holding less than 8% ownership that the licensee will
maintain workers compensation insurance as required by Utah law and rules and will maintain a copy of the documents
and information listed above at all times during active licensure.
I certify that I understand that DOPL may request these records and information at any time to determine compliance.
I declare under criminal penalty under the law of Utah that the foregoing is true and correct.
Signature of Authorized Signer: ____________________________________________________ Date: ____________
Knowingly making a false statement as provided under Utah Code Ann. §76-8-503 is a class B misdemeanor.
Printed Name and Position of Authorized Signer: ________________________________________________________
F-55dBAC-PI
20210701
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DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
OWNERSHIP LISTING
Please complete the following information for all officers, directors, shareholders owning more than 5% of the stock of
the company, partners, proprietors and responsible management personnel. Please make additional copies as needed.
Full Legal Name:
First
Middle
Last
SSN:
Date of Birth:
Gender: Male Female
Mailing Address:
Street Address (including Apt/Unit/Ste #) and/or PO Box
City
State
ZIP Code
Is this individual a Licensed Burglar Alarm Agent? Yes No
If yes, license number:
Full Legal Name:
First
Middle
Last
SSN:
Date of Birth:
Gender: Male Female
Mailing Address:
Street Address (including Apt/Unit/Ste #) and/or PO Box
City
State
ZIP Code
Is this individual a Licensed Burglar Alarm Agent? Yes No
If yes, license number:
Full Legal Name:
First
Middle
Last
SSN:
Date of Birth:
Gender: Male Female
Mailing Address:
Street Address (including Apt/Unit/Ste #) and/or PO Box
City
State
ZIP Code
Is this individual a Licensed Burglar Alarm Agent? Yes No
If yes, license number:
Full Legal Name:
First
Middle
Last
SSN:
Date of Birth:
Gender: Male Female
Mailing Address:
Street Address (including Apt/Unit/Ste #) and/or PO Box
City
State
ZIP Code
Is this individual a Licensed Burglar Alarm Agent? Yes No
If yes, license number:
All individuals listed must submit two (2) Fingerprint Cards and a $30.00 fingerprint processing fee to complete a BCI
and FBI background check, see https://dopl.utah.gov/fingerprints.html
for additional information. However, if the
individual holds a current Utah Alarm Agent License, fingerprints are not required.
F-55dBAC-OL
20210701
DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
CRIMINAL HISTORY DISCLOSURE STATEMENT
Each Individual listed on the Ownership Listing,
who is not currently licensed as a Burglar Alarm Agent,
must complete one of these forms.
Fingerprints submitted with this application are used to complete a search through the files of the Utah Bureau of
Criminal Identification (BCI) and the Federal Bureau of Investigations (FBI). Prior to submitting fingerprints, you
must read and acknowledge, by signing the affidavit below, the Privacy Act Statement found at:
https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement
. Physical copies of this statement may
also be obtained upon request from the Division.
The criminal record information obtained by this search will be used by Division staff to evaluate your ability to
obtain licensure in Utah. You may challenge or review your criminal record. For additional information regarding
the challenge or review process, please see below.
By signing below, you acknowledge receipt of this information and consent to the background check process
described above.
Signature: _______________________________________________________ _
Date: _________________ _
Printed Name: ______________________________________________________________
Burglar Alarm Company Name:
Burglar Alarm Company Address:
Please see our website, www.dopl.utah.gov/fingerprints.html, for required information
and approved locations to obtain fingerprints.
REVIEW OF YOUR CRIMINAL RECORD: If you wish to review or challenge the accuracy of the information in
your FBI record, you should contact the agency that contributed the information in question. You may also direct
the challenge to the FBI. Please see their website at: https://www.fbi.gov/services/cjis/identity-history-summary-
checks. You may also contact them via mail at: FBI: CJIS Division, Attn. Criminal History Analysis Team 1, 1000
Custer Hollow Road, Clarksburg, WV 26306. The FBI will forward the challenge to the respective agency.
If you wish to review or challenge the accuracy of the information in your BCI record, you must complete the
required “Record Challenge Form”, available at: https://bci.utah.gov/criminal-records/criminal-records-forms/, and
submit it directly to BCI.
Agency review of a licensing decision based on your criminal record may be obtained by filing a written request
for agency review with the Executive Director of the Department of Commerce within thirty (30) days after
notification of the decision. Any such request must comply with the requirements of Utah Code § 63G-4-301 and
Utah Admin. Code R151-4-902.
F-55dBAC-CHD
20210701
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signature
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DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
QUALIFIER EXPERIENCE AND EXAMINATION
If you have more than one qualifier, you must complete this section for each individual. Please make addition copies
as needed.
To be completed by the applicant:
Qualifier’s Full Legal Name:
First
Middle
Last
Utah Alarm Agent License:
Exp Date:
Previously approved as a qualifier for DOPL License (if applicable):
SSN:
Date of Birth:
Gender: Male Female
Association with Alarm Company:
Owner Director Partner W-2 Employee in Management Position
Each qualifier is required to pass the Utah
Burglar Alarm Company Qualifier Examination and Utah Burglar Alarm Security Law
and Rule Exam. DOPL’s testing provider will electronically send the results of your examination directly to DOPL.
Please see
the Exam section of our website, at: www.dopl.utah.gov/ba/ for complete information.
In addition to passing the required exams, each qualifier must provide the following items to complete the application:
An original record of criminal history or certification of no record of criminal history for the qualifier, issued by
the Bureau of Criminal Identification.
Documentation of at least 4 years of experience in the last 10 years. Please select one:
o Previously approved qualifier for Utah license listed above for at least 4 of the last 10 years.
o Provide documentation of 6,000 hours paid employment experience in the alarm company business
and 2,000 hours as a manager or administrator in the alarm company business or construction trade
below AND W2s from the company below OR tax returns showing ownership distribution from the
company covering the time listed below.
Note: If your experience was completed with more than one employer, each must complete a separate form.
To be completed by the Supervisor.
Name of Alarm Company
Name of Supervisor:
License Number:
Establishment Address:
Street/PO Box
City
State/Zip
Telephone Number:
Email:
Dates of Employment/Supervision:
to
MM/DD/YYYY
MM/DD/YYYY
Total Hours of Management or Administration Experience:
Total Hours of Paid Experience:
Is the applicant currently employed with the facility? Yes No
If no, is the applicant re-hirable? Yes No, Please explain:
I do hereby certify that the information provided above is true and accurate. I further certify that the applicant is
qualified and competent to practice as an Alarm Company Qualifier.
Signature of Supervisor: ______________________________________________ Date: _____________________
F-55dBAC-QE
20210701
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DOPL • Heber M. Wells Building • 160 East 300 South • P.O. Box 146741, Salt Lake City, UT 84114-6741
www.dopl.utah.gov • telephone (801) 530-6628 • toll-free in Utah (866) 275-3675 • fax (801) 530-6511
APPLICATION CHECKLIST AND INSTRUCTIONS
This checklist is for your convenience; you do not need to include it with your application.
NOTE: Incomplete applications will be denied.
Your application is classified as a public record and may be available for inspection by the public, except with
regard to the release of information which is sub-classified as controlled, private, or protected under the
Government Records Access and Management Act or restricted by other law.
The following items are required to complete your application
$331.00 non-refundable application-processing fee.
Supporting documentation for any “yes” answers provided on the “Qualifying Questionnaire”. See page 3
of the application for more information.
General Liability Insurance Certificate with a minimum required coverage of $300,000 for each incident
and $1,000,000 in total.
Proof of Workers Compensation Insurance (if applicable).
Copy of signed PEO contract (if applicable).
Supporting documentation as outlined in the Qualifier Education and Examination section. (See page 5 of
this application.)
Fingerprints for all individuals listed on the Ownership Listing (page 4 of this application) that do not hold
a current alarm company agent license to be used by DOPL for a fingerprint search through the files of
the Utah Bureau of Criminal Identification (BCI) and the Federal Bureau of Investigations (FBI). Please
see our website, www.dopl.utah.gov/fingerprints.html, for required information and approved locations to
obtain fingerprints.
$30.00 fingerprint processing fee for each individual that is required to be fingerprinted.
Submit the above items with your completed application to:
In person or via express delivery:
Division of Occupational and Professional Licensing
Heber M Wells Building, 1
st
Floor Lobby
160 E 300 S
Salt Lake City, UT 84111
US Postal Service:
Division of Occupational and Professional Licensing
PO BOX 146741
Salt Lake City, UT 84114-6741
F-55dBAC-CH
20210701
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Burglar Alarm Company (Utah DRE)

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Completed 26 January 2022

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