Verification Of License/registration Form - 2000
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1BUSINESS AND PROFESSIONS DIVISION
PRIVATE SECURITY GUARD SECTION
P.O. BOX 9649
OLYMPIA, WA 98507-9649
VERIFICATION OF LICENSE/REGISTRATION
FROM: Washington State Department of Licensing
Business and Professions Division
TO:
APPLICANT
In order to assist the state/jurisdication in which you hold current licensure/registration in providing information to this
agency, complete this section only and forward to the appropriate licensing authority in that state. That state/
jurisdiction may charge you a fee for this service.
/
/
Name __________________________________________________ Date of Birth ________________________
LAST
FIRST
MI
Address _____________________________________________________________________________________
City _____________________________________________ State ________________ Zip _________________
License/Registration/I.D. Card Number __________________________________ Expires __________________
/
/
TO:
LICENSING AUTHORITY
The above named individual is applying for licensure in Washington state as a Private Security Guard based upon his/
her license/registration in your jurisdiction. It would be appreciated if you would provide the information below to support
his/her application in Washington. The completed form may either be returned to the individual at the address provided
or forwarded directly to this office at the address above. Thank you for your assistance to this applicant.
State/Jurisdiction: _____________________________________________________________________________
License/Registration # _______________ Date Issued _____________________ Expires __________________
/
/
/
/
MO
DAY
YR
MO
DAY
YR
!
!
!
License/Registration As:
Unarmed Guard
Armed Guard
Principal of Company
!
!
Licensee met minimum preassignment training and testing requirements which consisted of:
Yes
No
(Please attach a copy of licensing prerequisites and training requirements)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
!
!
Are there any complaints against Licensee?
Yes
No
!
!
Is there any disciplinary activity pending against the Licensee?
Yes
No
If "YES" to above, type? ________________________________________________________________________
Any other imformation you are able to release will be appreciated. _______________________________________
___________________________________________________________________________________________
X
For the state of
Signature of Administrative Officer
Dated this _______ day of _____________, ______
The Department of Licensing has a policy of providing equal access to its services. If
you need special accommodation, please call (360) 664-9072 or TTY (360) 586-2788.
PSG-690-011 VERIF. OUT-OF-STATE (R/8/00)FM/W
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