Fillable Permanent Employee Registration Card (PERC) (State of Illinois Department of Financial & Professional Regulation)

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Permanent Employee Registration Card (PERC) (State of Illinois Department of Financial & Professional Regulation)

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1
(129) Permanent Employee
Registration Card (PERC)
New Application Checklist
Contents
General Information .........................................................................................................................................................................2
Instructions: ..................................................................................................................................................................................2
Qualifications/Exemptions: ..........................................................................................................................................................2
Application Requirements ................................................................................................................................................................3
Application Fees ...............................................................................................................................................................................4
Security Clearance Information ........................................................................................................................................................5
Illinois Fingerprint Vendors ..........................................................................................................................................................5
Out-of-State Fingerprint Vendors .................................................................................................................................................6
2
General Information
Instructions:
1. Before completing the application package, read each step. This will aid you in accurately completing your application
and eliminate any delay in processing.
2. Applicant must be at least 18 years of age to apply for a PERC in an unarmed capacity.
3. Submit the appropriate security clearance documents in the form of a fingerprint background check.
4. Disclosure of your U.S. social security number, if you have one, is mandatory, in accordance with 5 Illinois Compiled
Statutes 100/10-65 to obtain a license. The social security number may be provided to the Illinois Department of
Public Aid to identify persons who are more than 30 days delinquent in complying with a child support order, or to
the Illinois Department of Revenue to identify persons who have failed to file a tax return, pay tax, penalty or interest
shown in a filed return, or to pay any final assessment or tax penalty or interest, as required by any Tax Act
administered by the Illinois Department of Revenue, or to other entities for verification of identification.
5. If you have been issued a Permanent Employee Registration Card in the past, you may not apply for an
additional card. The application which you submit is valid for 3 years from date of receipt. If you have applied for
a Permanent Employee Registration Card within the past 3 years but did not complete the application process, or
previously had a PERC card than is now expired DO NOT submit another application. Contact the Division's Call Center
at 1-800-560-6420 and request the status of your application.
6. If your PERC has been lost you can print your PERC online by clicking here.
7. The PERC shall expire on May 31, 2018 and every 3 years thereafter. You will receive your PERC renewal by email
approximately 90 days prior to the expiration date of your PERC.
Qualifications/Exemptions:
Detective, Security Contractor, Alarm Contractor or Locksmith Licensees
If you possess a valid Illinois detective, security contractor, alarm contractor, or locksmith license, then a PERC is
not required to work for a licensed agency.
Peace Officer Exemption
A peace officer as defined in the Private Detective, Private Alarm, Private Security, Fingerprint Vendor and
Locksmith Act is exempt from the requirements relating to the possession of a permanent employee registration
card (PERC). The employing agency shall remain responsible for any peace officer employed under this exemption.
A person employed as an unarmed security guard at a nuclear energy, storage, weapons, or development site or
facility regulated by the Nuclear Regulatory Commission who has completed the background screening and
training mandated by the rules and regulations of the Nuclear Regulatory Commission is exempt from registration
for a Permanent Employee Registration Card.
If you wish to apply for the Peace Officer Exemption listed above. Include a completed Peace Officer
Exemption Form (VE-PEC) in your application. This form can be found at the back of this packet.
3
Application Requirements
Designation
Requirements
Submitted:
Permanent Employee
Registration Card
(PERC) with
Fingerprints (Illinois)
1. Completed online application including all required information
Date and Place of Birth
Social Security Number or an SSN Affidavit
Name Change Information
2. Record of Licensure: list all other related or non-related professional
licenses held in Illinois or another state(s).
3. You must be at least 18 years of age to apply for a Permanent Employee
Registration Card (PERC).
4. Fingerprint Information: the fingerprint Transaction Control Number
(TCN) from your fingerprint receipt. This number is 16 characters long
and can be found on the receipt provided by your fingerprint vendor.
Please keep your fingerprint receipt until your license has been issued.
The IDFPR may request it if any issues in the fingerprinting process arise.
5. Personal History Information (if applicable) including:
Criminal History
Felony Convictions
Dishonorable discharge from military service
Disease or conditions that may interfere with professional work
Denial of a prior professional license
6. Failure to comply with a child support order, defaulting on a student
loan, or defaulting on taxes.
ONLINE
PORTAL
Permanent Employee
Registration Card
(PERC) with
Fingerprints (Out-of-
State)
1. Completed online application including all required information
Date and Place of Birth
Social Security Number or an SSN Affidavit
Name Change Information
2. Record of Licensure: list all other related or non-related professional
licenses held in Illinois or another state(s).
3. You must be at least 18 years of age to apply for a Permanent Employee
Registration Card (PERC).
4. Fingerprint Information: the fingerprint Transaction Control Number
(TCN) from your fingerprint receipt. This number is 16 characters long
and can be found on the receipt provided by your fingerprint vendor.
Please keep your fingerprint receipt until your license has been issued.
The IDFPR may request it if any issues in the fingerprinting process arise.
5. Personal History Information (if applicable) including:
Criminal History
Felony Convictions
Dishonorable discharge from military service
Disease or conditions that may interfere with professional work
Denial of a prior professional license
6. Failure to comply with a child support order, defaulting on a student
loan, or defaulting on taxes.
ONLINE
PORTAL
4
Designation
Requirements
Submitted:
Permanent Employee
Registration Card
(PERC) with
Fingerprints (Out-of-
State)
1. Completed online application including all required information
Date and Place of Birth
Social Security Number or an SSN Affidavit
Name Change Information
2. Record of Licensure: list all other related or non-related professional
licenses held in Illinois or another state(s).
3. You must be at least 18 years of age to apply for a Permanent Employee
Registration Card (PERC).
4. Peace Officer Exemption: Upload a completed copy of form Verification
of Peace Officer Exemption (VE-PEC).
5. Personal History Information (if applicable) including:
Criminal History
Felony Convictions
Dishonorable discharge from military service
Disease or conditions that may interfere with professional work
Denial of a prior professional license
6. Failure to comply with a child support order, defaulting on a student
loan, or defaulting on taxes (if applicable).
ONLINE
PORTAL
Application Fees
Fees collected through the licensing process are NOT REFUNDABLE OR TRANSFERABLE.
Complete
License Type
Submitted:
ALL
DESIGNATIONS
(129) Permanent Employee Registration Card (PERC) …..…………………….….………… $55.00
ONLINE
PORTAL
NOTES: All major credit and debit cards as well as ACH and eCheck are accepted.
5
Security Clearance Information
Individuals applying for licensure for professions that require fingerprints must submit to a criminal background check
and provide evidence of fingerprint processing from a fingerprint vendor licensed by the Department. Fingerprints must
be taken within 60 days from the date that the application is submitted to the Department or the Department’s testing
vendor.
Illinois Fingerprint Vendors
1. Applicants may contact a licensed fingerprint vendor to schedule an appointment for fingerprinting by clicking
here. The Illinois State Police will transmit electronic results of fingerprint processing to the Department.
Applicants fingerprinted in Illinois will no longer be required to submit a physical copy of their live scan
receipt as a part of their initial license application. Instead, they will be required to enter their 16 digit
Transaction Control Number (TCN) found on the fingerprint receipt issued by their licensed fingerprint
vendor.
Applicants should still retain a copy of this fingerprint receipt until their license has been issued, as the
Department may request a copy of it if any issues in the fingerprinting process arise during the application
process.
6
Out-of-State Fingerprint Vendors
Out-of-State applicants who are unable to schedule an appointment for fingerprinting through a licensed fingerprint
vendor need to complete the following steps:
1. Obtain one (1) Illinois State Police (ISP) Fee Applicant Card for processing. Applicants may contact the
Department at 1-800-560-6420 or send an email request on your profession page of the Department website at
http://www.idfpr.com/. The ISP will transmit electronic results of the fingerprint processing to the Department.
2. Complete Section 1 of the Identity Verification Certifying Statement form (OOS-FP). See the end of this packet
for form OOS-FP.
3. The Fee Applicant Card shall be taken to a police department in another state to obtain classifiable prints.
4. Section 2 of the Identity Verification Certifying Statement form (OOS-FP) shall be completed and signed by the
police department.
5. Click here to select a licensed Illinois fingerprint vendor that has “Card Scan” capability. Contact the vendor to
determine the fee for a “Card Scan”.
6. Mail the original Identity Verification Certifying Statement form (OOS-FP) (with Sections 1 and 2 completed),
Fee Applicant Card and fingerprint fee to the licensed fingerprint vendor selected from the Division of
Professional Regulation website.
7. To verify applicants have completed the fingerprinting process, IDFPR will require applicants to enter the 16 digit
Transaction Control Number (TCN) found on their Fee Applicant Card issued by the Illinois State Police. This
number can be found in the upper-right hand corner of the Fee Applicant Card and begins with the letters
‘FRM’.
Applicants should still retain a copy of all OOS-FP-related forms until their license has been issued, as the
Department may request a copy of it if any issues in the fingerprinting process arise during the application
process.
IDENTITY VERIFICATION CERTIFYING
STATEMENT
OOS-FP
IMPORTANT NOTICE: Completion of
this form is necessary for licensure/
employment under provision set forth
within the Illinois Compiled Statutes or
other related Federal laws. Disclosure
of this information is VOLUNTARY.
However, failure to comply may result
in the denial of your application.
Pursuant to Title 68 Part 1240.535 of the Private Detective, Private Alarm, Private Security, Fingerprint Vendor, and
Locksmith Act of 2004 Rules, fi ngerprint vendors are required to confi rm identity of the individual seeking to be fi nger-
printed. This identity verifi cation form must be completed for out-of-state residents applying for licensure/employment in
the State of Illinois. This form will be utilized to confi rm the personal identifying information being placed on the Illinois
State Police (ISP) Fee Applicant fi ngerprint card, form number ISP-404. The out-of-state agency chosen to take your
fi ngerprints, must complete this form, as written confi rmation that a valid government issued drivers license or State ID
was presented and that the identifi cation provided, belongs to the individual being fi ngerprinted.
Instructions: This form must be submitted, along with a manual Fee Applicant fi ngerprint card to which your fi nger-
prints have been applied, to a licensed live scan fi ngerprint vendor in the State of Illinois possessing “Scan Card” capa-
bility to ensure electronic transmission of the Fee Applicant fi ngerprint card. The electronic transmission of fi ngerprints
to the ISP is mandated pursuant to Title 20 Part 1265 “Electronic Transmission of Fingerprints”. The manual submis-
sion of fi ngerprints to ISP is no longer acceptable. Once your fi ngerprints have been taken, a signed original of this
form must be attached to your Fee Applicant fi ngerprint card and submitted to an Illinois licensed live scan fi ngerprint
vendor. As well, an additional copy may be required to be submitted to the requesting State Agency along with any ad-
ditional application or required documentation specifi ed by the State Agency.
Section 2 Certifying Agency Taking Fingerprints (Include TCN from Fee Applicant card)
Section 3 Fingerprint Vendor Agency Name
Illinois Live Scan Fingerprint Vendor Information
AGENCY NAME:
TCN: FRM
DATE FINGERPRINT TAKEN: CONTACT PHONE NUMBER:
/ /
( ) -
PRINTING AGENT’S NAME: LAST FIRST
I have compared the government issued identifi cation presented by the applicant and attest that to the
best determination, I have fi ngerprinted the same individual. (Must be checked to certify)
PRINTING AGENT’S SIGNATURE:
LIVE SCAN FP AGENCY NAME:
REQUESTING STATE AGENCY: REQUESTING STATE AGENCY ORI:
DATE FINGERPRINTS SUBMITTED TO ISP:
COST CENTER USED:
IL486-2222 4/15
Section 1 Applicant Information (All fi elds mandatory)
MAIDEN NAME/GIVEN SURNAME:
ADDRESS: (STREET/CITY/STATE/ZIP)
LAST NAME: FIRST: MIDDLE:
POSITION / REASON FINGERPRINTED: (NURSE/DOCTOR/SECURITY GUARD, ETC)
SOCIAL SECURITY NUMBER:DATE OF BIRTH:
PHONE NUMBER:
IMPORTANT NOTICE: Completion of this form
is necessary for consideration for licensure under
225 ILCS 447/1 et. seg. (Illinois Compiled Statutes).
Disclosure of this information is VOLUNTARY.
However, failure to comply may result in this form
not being processed.
PEACE OFFICER EMPLOYMENT
VERIFICATION
VE - PEC
SUPPORTING DOCUMENT
Persons retired from a peace officer position* within 1 year of application are exempt from the fingerprint requirement for a
permanent employment registration card (PERC). If you meet the conditions of a Peace Officer*, complete the applicant section
of this form and forward it to the Law Enforcement Agency/Department for whom you worked for completion. After it is
completed, return it to this Department in lieu of the fingerprint cards. The employing agency shall remain responsible for any
peace officer employed under this exemption for a PERC, regardless if the peace officer is compensated as an employee or an
independent contractor.
* Peace Officer means any person who by virtue of his/her office or public employment is vested by law with a duty to maintain public order
or to make arrests for offenses, whether that duty extends to all offenses or is limited to specific offenses; officers; agents or employees of
the federal government commissioned by federal statute to make arrests for violations of federal laws shall be considered peace officers.
APPLICANT SECTION:
1.
LAST NAME:
FIRST NAME MIDDLE NAME
__ __ / __ __ / __ __ __ __
Month Day Year
2. DATE OF BIRTH
3.
BADGE OR IDENTIFICATION NUMBER
3.
US SOCIAL SECURITY NUMBER:
I hereby authorize to furnish to the Illinois Department of
Financial and Professional Regulation or its designated testing service, the information requested below.
Name of Law Enforcement Agency / Department
Signature
Date
Complete this section and return it for inclusion in the
professional's license application.
LAW ENFORCEMENT AGENCY SECTION:
A. NAME OF SUPERVISOR / PERSONNEL OFFICER:
B. NAME OF LAW ENFORCEMENT AGENCY OR DEPARTMENT
C. BUSINESS PHONE NUMBER
Area Code ( ___ ___ ___ ) ___ ___ ___ — ___ ___ ___ ___
D. BUSINESS ADDRESS (STREET, CITY, STATE, ZIP CODE)
Date Applicant Retired from Law Enforcement Agency / Department: ___ ___ /___ ___ /___ ___ ___ ___
Month Day Year
E.
I do hereby declare that the information I have recorded is true and correct.
Date
Signature
PRINT NAME OF SUPERVISOR / PERSONNEL OFFICER
IL486-1578 12/15 (DE)
EMPLOYEE NUMBER
Date: Signature of Employee:
IL486-0495 6/16 (DE)
NAME OF EMPLOYEE SOCIAL SECURITY NUMBER
ADDRESS OF EMPLOYEE (Include Street, City, State, and ZIP Code)
DATE OF BIRTH (Month/Day/Year) PLACE OF BIRTH
NAME AND ADDRESS OF EMPLOYING AGENCY
Please state business or occupation engaged in for the fi ve (5) years immediately preceding the date of execution of this
statement, the location of such business or occupation, and the names of employers, if any.
EMPLOYEE'S STATEMENT
To be retained in employee's personnel fi le by the em-
ploying agency.
DATE OF EMPLOYMENT
IMPORTANT NOTICE: Completion of this form
is necessary to accomplish the requirements
outlined in 225 ILCS 447/1 et. seq. (Illinois
Compiled Statutes). Disclosure of this information
is REQUIRED. Failure to provide any information
will result in this form not being processed.
Yes No
Yes No
Have you ever had a license or registration denied, suspended or revoked under the Illinois Private Detective,
Private Alarm, Private Security, Fingerprint Vendor and Locksmith Act? Yes No
If yes, attach explanation.
Have you been convicted of or pled guilty or nolo contendere to any criminal offense in any state or in
federal court? Please do not give details on minor traffi c charges, but do include information relating to
Driving While Intoxicated (DWI) charges. If yes, attach a certifi ed copy of the court records regarding your
conviction, the nature of the offense and date of discharge, if applicable, as well as a statement from the
probation or parole offi ce.
Have you ever been discharged other than honorably from the armed services or from a city, county, state,
or federal position? If yes, attach explanation.
Do you have any disease or condition that interferes with your ability to perform the essential functions of
your profession, including any disease or condition generally regarded as chronic by the medical community,
i.e., (1) mental or emotional disease or condition; (2) alcohol or other substance abuse; (3) physical disease
or condition, that presently interferes with your ability to practice your profession? If yes, attach a detailed
statement, including an explanation whether or not you are currently under treatment.
Yes No
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