Fillable PRIVATE DETECTIVE EMPLOYEES STATEMENT Division of State Police (New Jersey State Police)

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PRIVATE DETECTIVE EMPLOYEES STATEMENT Division of State Police (New Jersey State Police)

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PRIVATE DETECTIVE EMPLOYEE’S STATEMENT
Division of State Police
Department of Law and Public Safety
State of New Jersey
All information entered on this form is considered to be offered as a sworn statement. Any misstatement of fact is
reason for disqualifi cation for employment, or may be punishable by law as per N.J.S. 2C:28-2, 2C:28-3 and 2C:28-7.
No person shall be employed by any holder of a private detective license until such person to be employed shall have
executed and furnished to such license certifi cate holder the following statement, pursuant to the provisions of “The Private
Detective Act of 1939” as amended by Chapter 152, Laws of 1948.
A copy of the Sagem Morpho Receipt must be attached to this statement as proof of fi ngerprinting.
The statement must be made in the handwriting of the person to be employed by the holder of a private detective
license and must be retained by the employer.
Employee’s Number ____________. All employees’ statements must be numbered consecutively, commencing with
Number 1. A number once assigned cannot be used for any other employee. Upon a subsequent rehire of any employee, that
employee should again be assigned his old number. The number entered here must be identical with the number entered on
the fi ngerprint sheets.
Employer: To be completed in indelible ink.
Name of Licensee: ______________________________________________________________________
Trading as: ____________________________________________________________________________
Address:______________________________________________________________________________
Date License Issued: __________________________ Number of License: _________________________
1. a. Name of Employee in Full __________________________________________ S.S. No. ____________________
b. Residence Address ____________________________________________________________________________
c. Home Phone: ____________________ Cell Phone: ____________________ Email: ______________________
d. Age _____ Birth Place and Date ________________________________________________________________
e. Are you a citizen of the United States? _____________. If not, have you fi led your declaration of intention to
become a citizen? __________ If fi led, when and where? ____________________________________________
f. If you are not a citizen of the United States, of what country are you a citizen or subject? ____________________
S.P. 202 (Rev. 04/07)
(Date) (City) (County) (State) (Country)
(Date) (Name of Court) (City) (State)
2. Give your business or occupation engaged in for the fi ve years immediately preceding the date of the fi ling of this
statement with your employer, setting forth the place or places where such business or occupation was engaged in and
the name or names of employers, if any, with dates thereof:
3. Have you ever been indicted for any crime or offense in this State or any other State or Territory? __________
If so, give full details.
___
_________________________________________________________________________
_____
______________________________________________________________________________________________
4. Is there any complaint against you now pending before any department, bureau, board, prosecuting offi cer, criminal
court or any other governmental or regulatory body or offi cer? ______________ If so, give details.
5. Have you ever been convicted of a high misdemeanor, or a crime of the fi rst or second degree? __________________
If so, give details
_____
____________________________________________________________________________
_____________
6. Have you ever been convicted of:
a. Illegally using, carrying or possessing a pistol or other dangerous weapon? _______________________________
b. Making or possessing burglar’s instruments? _______________________________________________________
c. Buying or receiving stolen property; larceny or theft? ________________________________________________
d. Unlawful entry of a building? ___________________________________________________________________
e. Aiding escape from prison? _____________________________________________________________________
f. Unlawfully possessing, under the infl uence of, or distributing habit-forming narcotic drugs or any controlled
dangerous substance? _________________________________________________________________________
Month/Year
Residence
(Give number, street & city)
Occupation
Name and Address
of Employer
From _____ /_____
To _____ /_____
From _____ /_____
To _____ /_____
From _____ /_____
To _____ /_____
From _____ /_____
To _____ /_____
From _____ /_____
To _____ /_____
7. Have you ever been convicted of any other crime or offense?__________ If so, give full details. __________________
______________________________________________________________________________________________
______________________________________________________________________________________________
8. a. Has any private detective’s license issued to you or to a partnership or corporation of which you were a member
or offi cer, ever been revoked in this State or any other State or Territory because of conviction of any of the
crimes or offenses specifi ed in this section? __________ If so, give full details
___________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
b. Has any application submitted by you for license as private detective ever been denied by this State or any other
State or Territory because of conviction of any crimes or offenses specifi ed in the preceding section? __________
If so, give full details
__________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
9. Has any license or permit issued to you or applied for by you ever been denied, suspended or revoked anywhere?
___________ If so, give full details
_________________________________________________________________
____
______________________________________________________________________________________________
10. Have you ever been dismissed for cause in any employment? _________ If so, give full details _________________
______________________________________________________________________________________________
______________________________________________________________________________________________
11. The name of the employer (licensee) to whom this statement is submitted is _________________________________
______________________________________________________________________________________________
STATE OF NEW JERSEY
City of ________________________________________
County of _____________________________________
s.s
__________________________________________________________________________________________
(Name of Person Making This Statement)
being duly sworn, deposes and says: that he is the person above named; that he has read the foregoing statement and the
answers thereon noted; that such answers are true to his knowledge, and that he personally attached his signature to this af-
fi davit; that the above answers were written in the handwriting of deponent.
Signed ______________________________________
Sworn before me this _______________________________
day of _________________________________, _________
(year)
_________________________________________________
Notary Public
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PRIVATE DETECTIVE EMPLOYEES STATEMENT Division of State Police (New Jersey State Police)

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Completed 29 July 2020

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