CERTIFICATE OF PHYSICAL AND MENTAL FITNESS
CITY AND COUNTY OF DENVER
SECURITY GUARD APPLICATION
REVISED 04/10/19
Date
This form must be filled out by a Physician / Physician's Assistant, licensed by the Colorado
Medical Board, or a Registered Nurse, licensed by the Colorado State Board of Nursing.
Legal Name of Applicant: _______________________________________________________________________
The above named individual (the Applicant) intends to make an application to be licensed as a Security
Guard in the City and County of Denver. The purpose of this examination is to determine if, in your
professional capacity as a licensed Physician, Registered Nurse or Physician's Assistant, you
consider the Applicant to be an emotionally stable person, of sound mind and in good physical condition.
___________________________________________________________________________________
Examiner's Information
Name: ____________________________________________________________________________________
License Prefix and Number: _________________________ Work Telephone Number: ___________________
Work Address: ______________________________________________________________________________
Date of Exam: ___________________________
a) Observing, investigating, and/or reporting unlawful activity.
b) Preventing or detecting theft or misappropriation of goods, money or other items of value.
c) Protecting individuals or property from harm or misappropriation.
d) Taking enforcement action by physically detaining or ejecting persons from premises.
e) Controlling access to protected premises, except as otherwise provided in sections 42-132(c).
Physician’s Signature
SECURITY GUARD RESPONSIBILITES
Security services means the performance of at least one of the following activities:
CIRCUMSTANCES OF CONCERN
EXAMINER INFORMATION
Date of Exam: _____________________________ License Prefix & Number:____________________________
Name: _________________________________________ Work Telephone: ____________________________
Work Address: _______________________________________________________________________________
Assistant or Registered Nurse
li
censed in
the
State
of
Colorado,
do
attest
that
I
have
exami
ned
the
above
named individual and find that the Applicant is physically, mentally and emotionally capable of performing the
duties required in the role of Security Guard.
Print Name Legibly
If, as the result of this examination, the Examiner is unable to attest to the physical, mental and emotional fitness of
the Applicant, please provide full details in the space below, printed legibly. Such as but not limited to, the Applicant
showing signs or giving a history of experiencing seizures, heart trouble, vertigo, psychiatric illness, or any other
observation or history related to body or mind which might render the Applicant unfit for the duties of a Security Guard.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
STATEMENT OF EXAMINATION
I, _____________________________________________________________________, being a Physician, Physician's
Print Name Legibly
click to sign
signature
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