Form Pi-1 - Application For Licensure - Oregon Department Of Public Safety Standards And Training Page 3

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Applicant’s Investigative Business Information – ORS 703.480
2
This information is required by ORS 703.480(2)(c) and will appear on the DPSST PI website in a publicly
searchable document.
Business Name:
Business Mailing Address:
(May be a PO Box)
Telephone:
Agent for Service of Process for Out of State Investigators ONLY
Business Name_____________________________________Contact Person: ____________________________________
Oregon Address _____________________________________________________________________________________
City _________________________________ Zip _____________ Phone _______________________________________
Residence History - 10 Years
3
Provide the last 10 years of residence history beginning with current residency.
(Please list additional residences on a separate sheet)
State
City
Years
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
Employment - 10 Years
4
Provide the last 10 consecutive years of employment history.
(
)
Please list additional employers on a separate sheet
Current Employer (
):_________________________________________________________________
5
Name & Address
Start Date:_______________ Job title:
Previous Employer (
):____________________________________________________________
Name & Address
Start Date:
End Date:
Previous Employer (
): ____________________________________________________________
Name & Address
Start Date:
End Date:
Previous Employer (
): ____________________________________________________________
Name & Address
Start Date: ______________ End Date:_________________
PI-1 Application for Licensure
Revised: 11/2016

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