I attest that
Subscribed and sworn to before me this
STATEMENT OF EDUCATIONAL BACKGROUND
TO REGISTER AS A GUARD UNDER
HRS CHAPTER 463 and ACT 208 (2010)
Access this form via website at : cca.hawaii.gov/pvl
PART I. TO BE COMPLETED BY APPLICANT
Fill in your NAME and ADDRESS only. Your supervisor/employer must complete the other sections and have the form
notarized. After it is completed, ATTACH it to your application form.
NAME OF APPLICANT (First, Middle) (Last)
Address of Applicant Other names used:
PART II. TO BE COMPLETED BY YOUR CURRENT OR FORMER EMPLOYER
An individual applying to register as a guard under HRS chapter 463 and Act 208, SLH 2010 is required to have a high school
education or its equivalent. The following attestation made and signed by the employer may be accepted as equivalent to a high
school education.
PDG-31 0615R
Phone No.:Provide date your application was submitted:
Name of Applicant
has had at least
understand verbal instructions, has a reasonable degree of verbal skill, and is able to write clear, factual reports.
I hereby certify that the statements, answers, and representations made in this statement and any attachments thereto are true
and correct. I understand that any misrepresentation is grounds for refusal to register the applicant as a guard, and is a
misdemeanor (see, HRS sections 710-1017, 436B-19, and 463-4).
years of work
Signature of Employer/Certifier in front of Notary Public
Print Name of Employer/Certifier
Date
day of A.D. 20
.
Notary Signature:
Notary Public, State of:
My commission expires:
Print Name:
This material can be made available for individuals with special needs. Please call the Licensing Branch Manager at (808) 586-3000 to submit your request.
Doc. Date: No. of Pages:
Notary Name: Circuit Court:
Doc. Description
Notary Signature:
Date:
experience from to
month/year month/year
demonstrating the ability to read, comprehend, apply written directions, and
