Fillable SECURITY AGENCY EMPLOYEES STATEMENT Division of State Police (New Jersey State Police)

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SECURITY AGENCY EMPLOYEES STATEMENT Division of State Police (New Jersey State Police)

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SECURITY AGENCY 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 security agency license until such person to be employed shall have
executed and furnished to such license holder the following statement, pursuant to the provisions of “The Security Offi cer
Registration Act (SORA)” as amended by Chapter 134, Laws of 2004.
The statement must be made in the handwriting of the person to be employed by the licensed security agency and must
be retained by the security agency.
Employee’s Temporary ID Number or Security Offi cer Certifi cation Number_____________________.
Employer: To be completed in indelible ink.
Name of Security Agency: ________________________________________________________________
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. 202A (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 dismissed for cause in any employment? _____________ If so, give full details.
___________________________________________________________________________________________
4. Has any license or permit issued to you or applied for by you ever been denied, suspended or revoked anywhere?
_____________ If so, give details.
5. Have you ever been convicted of buying or receiving stolen property, larceny or theft? ___________If so, give details.
6. Have you ever been convicted of aiding escape from prison? _____________ If so, give full details.
7. Have you ever been convicted of making or possessing burglar’s instruments? _____________ If so, give full details.
8. Have you ever been convicted of unlawfully possessing, under the infl uence of, or distributing habit-forming narcotic
drugs or any controlled dangerous substances? _____________ If so, give full details.
Month/Year
Residence
(Give number, street & city)
Occupation
Name and Address
of Employer
From _____ /_____
To _____ /_____
From _____ /_____
To _____ /_____
From _____ /_____
To _____ /_____
From _____ /_____
To _____ /_____
From _____ /_____
To _____ /_____
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
9. Have you ever been convicted of illegally using, carrying, or possessing a pistol or other dangerous weapon?
_____________ If so, give full details.
10. Have you ever been convicted of unlawful entry of a building?_____________ If so, give full details.
11. Have you ever been convicted of a crime of the fi rst, second, third or fourth degree?_________ If so, give full details.
12. Have you ever been indicted for any crime or offense in this State or any other State or Territory?_____________
If so, give full details.
13. Has any security agency 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.
14. Have you ever been convicted of any other crime or offense?_____________ If so, give full details.
15. Has this State or any other State or Territory ever denied any application submitted by you for license as a security
offi cer because of any crime or offenses specifi ed in the preceding questions? _____________
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SECURITY AGENCY EMPLOYEES STATEMENT Division of State Police (New Jersey State Police)

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Completed 29 July 2020

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