Rev. March 2020 Page 2 of 5
Check box if you are an ACTIVE DUTY PEACE OFFICER, as defined in Chapter 4.5 (commencing with section 830)
of Title 3 of Part 2 of the Penal Code, or a federal qualified law enforcement officer, as defined in section 926B of Title
18 of the United States Code.
Disclosure is voluntary. If you are seeking a peace officer exemption, check the box and provide additional
information for the Bureau to determine your eligibility. Read
Active Duty Peace Officer Exemptions
information under Instructions carefully to avoid delays in the processing of your application.
PROOF OF COMPLETING POWER TO ARREST TRAINING COURSE
Mandatory Disclosure Language
Submission of the requested information is required unless otherwise noted as optional. The Bureau of Security and Investigative
Services (BSIS) of the Department of Consumer Affairs (Department) cannot process your Security Guard Registration Initial
Application unless all required information is provided. Your fingerprints will be used to check the criminal history records of the FBI.
You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The
procedures for obtaining a change, correction, or updating an FBI identification record are set forth in Title 28, Code of Federal
Regulations (CFR) Section 16.34. Procedures for obtaining a copy of the FBI criminal history record are set forth at Title 28, CFR
Section 16.30 through 16.33, which you can view by visiting https://www.edo.cjis.gov.
Pursuant to the Information Practices Act, the BSIS is responsible for maintaining the information in this application. You have the right
to review the records maintained on you by the BSIS or Department unless the records are exempt from disclosure by section 1798.40
of the Civil Code. Your completed application becomes the property of the BSIS and will be used by authorized personnel to determine
your eligibility for a security guard registration. Information on your application may be transferred to other governmental or law
enforcement agencies, as permitted by law.
Pursuant to the California Public Records Act (Gov. Code § 6250 et seq.) and the Information Practices Act (Civ. Code § 1798.61),
information about persons possessing a license, certificate, permit or registration may be disclosed by the BSIS unless otherwise
specifically exempt from disclosure under the law. The Address of Record of each licensee is not exempt from disclosure and will be
released upon request by a member of the public. The BSIS makes every effort to protect the exempt personal information you provide
us. Exempt information provided by you, however, may be disclosed in response to a court or administrative order, a subpoena, or a
search warrant.
Pursuant to Business and Professions Code section 30, providing your social security number is mandatory and will be used primarily
for tax enforcement purposes and for compliance with any judgment or order for family support in accordance with section 17520 of the
Family Code. If you fail to provide your social security number, you will be reported to the Franchise Tax Board (FTB), which may assess
a $100 penalty against you. Further, pursuant to section 30, subdivision (m), your social security number together with your name, date
of birth, and license information may be shared with the Office of the Chancellor of the California Community Colleges. The Bureau is
legally prohibited from processing your application if you fail to provide your social security number or individual taxpayer identification
number.
The State Board of Equalization (BOE) and the FTB may share taxpayer information with the BSIS. You are required to pay your state
tax obligation. This application may be denied, or your license may be suspended if the state tax obligation is not paid and your name
appears on either the BOE or FTB certified list of top 500 tax delinquencies.
For questions about this notice or access to your record, you may contact the BSIS by mail at Bureau of Security and Investigative
Services, Attn: Custodian of Record, P.O. Box 980550, Sacramento, CA 95798-0550; by phone at(800) 952-5210; or by e-mail at
bsis.prarequests@dca.ca.gov.
For questions about the Department’s Privacy Policy, you may contact the Department of Consumer
Affairs by mail at 1625 North Market Boulevard, Sacramento, CA 95834, by phone at (800) 952-5210 or by e-mail at dca@dca.ca.gov.
I DECLARE UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE STATE OF CALIFORNIA, THAT:
• I personally completed this application;
• To the best of my knowledge all statements on this application are true and correct;
• I completed the 8-hour Power to Arrest training course required for a BSIS security guard registration or am
an active duty peace officer who has successfully completed a power to arrest course; and
• With full knowledge that all statements herein are subject to investigation and that any false or dishonest
information provided on the application may be grounds for denial or subsequent revocation of my security
guard registration and any other license(s) I hold, or may subject me to criminal prosecution
.
Applicant Signature Date
BSIS License/Certificate/Approval Number
School/Business Phone Number (Optional) School/Business Name Where Training Completed
Date Training Completed Certificate of Completion Serial Number
A Security Guard applicant must complete the BSIS eight (8) hour "Power to Arrest" training including passage of the BSIS
Power to Arrest Training Manual exam with a 100% score. This training can be obtained from a BSIS Private Patrol
Operator licensee, a BSIS-certified training facility, or a BSIS-approved Power to Arrest Trainer.
