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Form Ps-24 - Executive Manager - Oregon Department Of Public Safety Standards And Training Page 2

PS-24

Executive Manager Form

Instructions

These instructions will assist you in accurately filling out the form

Executive Manager Information – section 1

Enter your name and PSID, if no PSID assigned, use N/A.

Business name you are providing executive manager services for.

Enter email and contact phone number.

Are you the primary contact executive manager for the business? If not, tell us who is.

General Information – section 2

Check mark the box for either new business, updates or no change of information.

Enter business name.

Date you will begin employment OR date your employment was terminated.

Enter physical and mailing address.

If the location is exempt from disclosure per law, check box.

Enter business owner name.

Enter business website, if applicable.

Contract Executive Manager Information –section 3

If you are contracting your executive manager license to an employer, you must complete this section.* Leave blank if not

contracting your executive manager license with an employer.

Enter the business name of which you are entering a contract to provide executive manager services for.

Enter physical address only.

Date you are entering the contract OR date you are ending the contract.

*This section does not apply to private security businesses that provide contract private security services for businesses

or events. This is pertaining to an executive manager license only, i.e. you contract your license and the employer has

their own certified staff but no executive manager.

Oregon Administrative Rule Information

Executive managers must submit a completed Form PS-24 (Executive Manager Information Form) within 48 hours of a

change when:

(A) Beginning employment or entering a contract with an employer as an executive manager;

(B) Terminating employment or completing a contract for an employer as an executive manager; and

12/2017 – Instructional page

Form Ps-24 - Executive Manager - Oregon Department Of Public Safety Standards And Training Page 2