Fill - Free fillable Burglar Alarm Company Agent Application (Utah DRE) PDF form

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 Agent Application

APPLICANT INFORMATION

Full Legal Name:

First

Middle

Last

All Previous Legal Names:

Other DOPL Licenses Held:

SSN:

Date of Birth:

Gender: Male Female

Address:

Street Address (including Apt/Unit/Ste #) and/or PO Box

City

State

ZIP Code

Phone:

Email:

Note: All Division notices and communication will be sent to this email.

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 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.

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 Applicant: ______________________________________________ Date __________________________

F-55dBA-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

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.

PROFESSIONAL LICENSES

List all other licenses, registrations or certification 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:

IMINAL HISTORY DI

F-55dBA-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

CRIMINAL HISTORY DISCLOSURE STATEMENT

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: ____________________________________________________________________________

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.

TEMPORARY PERMIT

If you are applying for a Temporary Permit for Call Center, Office or Administrative burglar alarm company position,

complete this application, and submit it to your employer. Your employer will complete the section below and submit

the additional required documents to DOPL directly.

Employing Alarm

Company:

Company License

Number:

Employer

Contact:

Contact E-Mail

Contact

Phone:

F-55dBA-CHD

20210701

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signature

click to edit

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 INSTRUCTION

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:

 $91.00 non-refundable application-processing fee, made payable to “DOPL”.

 Supporting documentation for any “yes” answers provided on the “Qualifying Questionnaire”. See page 2

of the application for more information.

 Fingerprints 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.

If you are applying for a Temporary Permit for Call Center, Office, or Administrative burglar alarm

company position, complete this application and submit it to your employer.

Additional items needed for Temporary Permits applicants ONLY:

 $20.00 non-refundable temporary permit processing fee, made payable to “DOPL”.

 Letter from the employing company attesting to the fact the applicant is employed by the company and

meets the requirements outlined in law to qualify for a temporary permit.

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

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-55dBA-CH

20210701

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