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Indiana Professional Licensing Agency

APPLICATION FOR PRIVATE DETECTIVE LICENSE

Private Detective Licensing Board

State Form 43777 (R7 / 9-01)

302 West Washington Street, Room E034

Approved by State Board of Accounts, 2001

Indianapolis IN 46204-2700

* Your Social Security number and/or Federal Identification number is requested in accordance with the provisions of IC 4-1-8-1. Disclosure is mandatory.

The number will be given to the Indiana Department of Revenue.

Pursuant to IC 25-30-1, concerning the regulation and licensing of the private detective business and private detectives in the State of Indiana, the following

questions shall be answered, and the required information given, by each individual applicant and, if the applicant is a corporation or partnership, its officers

or partners for Private Detective License.

Use a separate sheet of paper to complete answers to any question, if necessary.

INSTRUCTIONS

Submit original copies of your, or if a corporation or partnership, its officers or partners, review challenge (limited criminal history) received from

the applicable state and local police records (city and county of residence).

Registration of each employee shall be filed with a completed identification card and a ten dollar ($10) fee.

Any applicant employing more than fourteen (14) employees shall submit proof of one hundred thousand dollars ($100,000) per occurrence liability

insurance. Applicants employing less than fifteen (15) employees shall submit proof of seven thousand dollars ($7,000) surety bond, or proof of one

hundred thousand dollars ($100,000) per occurrence liability insurance.

Recent photo.

Set of fingerprints of both hands, taken by a police official.

APPLICANT INFORMATION

Name of applicant (type or print)

Social Security number *

Position of applicant (state either "Individual" or name of position held)

Name under which applicant intends to do business

Business Address (number and street)

Business telephone number

(

)

City, state, ZIP code

Resident address (number and street)

Resident telephone number

(

)

City, state, ZIP code

If a Corporation applicant, have all statutory

Date of birth

How long have you been a resident of Indiana?

prerequisites to the doing of business in Indiana

Yes

been satisfied?

Federal identification number *

(ATTACH A COPY OF CORPORATE FILINGS)

EDUCATION INFORMATION

Name of high school (if a graduate)

Address (number and street, city, state, ZIP code)

College(s) attended

College from which degree received

Degree received

List post-graduate degree(s), if any, and schooling which you have completed and consider to better qualify you for purposes of this application.

CRIMINAL RECORD INFORMATION / SUBMISSIONS

Have you, any employee, or if a corporation or partnership, its officers, directors, partners, employees or members ever

been convicted of any crime? (If YES, on back page, state what crime[s], name and location of court[s] of conviction, the

Yes

sentence[s] of the court[s], and attach documentation of conviction[s].)

Have you, any employee, or if a corporation or partnership, its officers, directors, partners, employees or members ever

been convicted of any act which, under the provisions of the Indiana Detective License Law (IC 25-30-1), would be

grounds for denial, suspension, or revocation of a private detective license? (If YES, on back page, state what crime[s],

Yes

name and location of court[s] of conviction, the sentence[s] of the court[s], and attach documentation of conviction[s].)

State Form 43777 - Application For Private Detective License - Indiana Professional Licensing Agency

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