DOS-1496-f-a (Rev. 10/15) Page 2 of 2
Security or Fire Alarm System Installer Qualifying Course Approval Application
5. TYPE OF EDUCATIONAL ORGANIZATION OWNERSHIP
Is this organization an accredited College or University? Yes No* If No*, Please complete one of the following:
INDIVIDUAL: (Please submit a certified copy of the Trade Name Certificate and complete the following for Owner.)
NAME HOME ADDRESS (NUMBER AND STREET)
CITY STATE ZIP+4
PARTNERSHIP: (Please submit a copy of Partnership Agreement and complete the following for all Partners.)
NAME HOME ADDRESS (NUMBER AND STREET)
CITY STATE ZIP+4
NAME HOME ADDRESS (NUMBER AND STREET)
CITY STATE ZIP+4
CORPORATION: (Please submit a copy of the Certificate of Incorporation and complete the following for all officers and other individuals who own 5% or
more of the stock of this corporation. If needed, attach additional sheets.)
NAME HOME ADDRESS (NUMBER AND STREET)
CITY STATE ZIP+4
NAME HOME ADDRESS (NUMBER AND STREET)
CITY STATE ZIP+4
NAME HOME ADDRESS (NUMBER AND STREET)
CITY STATE ZIP+4
6. Has any owner, partner, owner of 5% or more of the stock of the entity, or individual authorized to submit this application on behalf of the
entity been convicted of any crime or offense, other than a minor traffic violation?
Yes* No If Yes*, submit a certified copy of each conviction.
7. Has any license or permit issued to, applied for by any owner, partner, holder of 5% or more of the stock of the entity, or individual
authorized to submit this application on behalf of the entity, been denied, suspended or revoked by this state or elsewhere by any other
government or regulatory body?
Yes* No If Yes*, please provide details.
8. COURSE CONTENT- ALL OF THE FOLLOWING MUST BE SUBMITTED:
a detailed course outline for each course with time sequence of each segment. (See section 196.9 for curriculum.)
the final examination to be presented for the course, including the answer key, reference page and source and subject matter category.
a description of materials that will be distributed.
the books that will be utilized in the course and final examination.
a sample certificate of successful completion as described in Section 196.13.
list of names and signatures of individuals authorized to sign certificates.
Correspondence Courses (see Sections 196.6 and 196.7):
in addition to the above, you must submit a complete description of the method in which the course will be presented.
the complete lesson plan that will be issued to the student.
a complete description of the method as to how the final examination will be conducted.
I subscribe and affirm under the penalties of perjury that the statements made in this application (including statements made in any accompanying papers) have
been examined by me, and to the best of my knowledge and belief, are true and correct.
I understand that any misstatement made on this application for approval could result in an immediate revocation or withdrawal of the recognition of the
approval of the entity by the Department of State.
Coordinator Signature
X
Date
