Form Ps-24 - Executive Manager - Oregon Department Of Public Safety Standards And Training
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1
2PS-24
Executive Manager Form
Department of Public Safety Standards and Training / Private Security Certification & Licensing Program
4190 Aumsville Hwy SE, Salem, OR 97317-8983
Phone: 503-378-8531 / Fax: 503-378-4600
E-mail:
dpsst.security@state.or.us
Website:
ALL INFORMATION BELOW IS REQUIRED TO BE SUBMITTED WITHIN 48 HOURS OF A CHANGE
Executive Manager Information
1
Executive Manager Name/PSID:
Business Name:
(If no PSID assigned, use N/A)
Email:
Contact Phone Number:
No – complete next line
Are you the primary contact executive manager for the business?
Yes
Primary contact executive manager:
General Information
New
Update info
No changes
2
Business Name:
Beginning employment on:
Ended employment on:
Physical Address:
City:
State:
Zip:
Check box if your location is exempt from disclosure - marijuana processor, producer or wholesaler
Business Phone:
Business Fax:
Tax Payer ID:
Mailing Address (If different):
City:
State:
Zip:
Business Owner(s) Name(s):
Business Website Address:
Contract Executive Manager Information
3
Business Name:
Physical Address:
City:
State:
Zip:
Entering contract on:
Ending contract on:
The information contained on this form is true and correct to the best of my knowledge. I understand that falsification
of any documents submitted to the Department may be cause for denial, suspension or revocation of certification or
licensure under ORS 181A.870 and OAR 259-060-0300, and subject to a civil penalty under OAR 259-060-0450.
Signature____________________________________________________________________Date_____________
12/2017
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