Licensing Reciprocity Standard for Alarm Monitoring Organizations
(CSAA.LIC1)
January 1998
Prepared and
Submitted by CSAA Standards Committee © CSAA 1998
APPENDIX
A
EMPLOYEE'S
STATEMENT
Employee Number:
SSN:
Employer
Name Of Licensee:
Address:
Date of License Issued
Number of License:
1a. Name of
Employee (in full):
b. Residence Street Address:
City:
State:
County:
Zip:
c. Age:
Date of Birth:
d. U.S. Citizen? Y / N
e. If answer to 1d is no, are you a legal permanent resident
of the U.S. in possession of a work
authorization? Y / N
If no, please explain:
2
List the businesses or occupations you have engaged in for five years
immediately
preceding the date of the filing
of this statement with your employer, including the
place(s) where the business or occupation
was engaged in and the names of
employers, if any, and dates thereof:
If there are any gaps between
listed periods of business or employment, please explain why:
As part of the application process you will be required to sign documents
allowing us to have
access to federal and state
criminal files.
3
Have you been dismissed from any employment for any reason other than
lack of work? ........................................................................................................
Y / N
If yes, please give dates, nature and place of such employment,
name and
address of employer(s) and reason(s)
for such dismissal:
4
Have you ever been convicted of a felony in this State or elsewhere? ..............
Y / N
5
Have you ever been convicted in this State or elsewhere of:
a Any offense involving moral turpitude? .............................................................
Y / N
b Illegally using, carrying or possessing a pistol
or other dangerous weapon? ..... Y / N
c Making or possessing burglar's instruments?
.................................................... Y / N
d Buying or receiving stolen property? .................................................................
Y / N
e Unlawful entry of a building? ............................................................................
Y / N
f Aiding escape from prison? ................................................................................
Y / N
g Unlawfully possessing or distributing controlled
substances? ............................ Y / N
h Except for minor traffic infractions, have
you ever been convicted of any
other offense in this State
or elsewhere? .............................................................
Y / N
6
Are you presently under indictment for any crime or offense in this State
or
elsewhere? ............................................................................................................
Y / N
7
Have you ever been dishonorably discharged from the armed forces? ................
Y / N
8a Has
any private detective, private investigator, watchguard or patrol agency
license issued to you or to a partnership
or corporation of which you were a
member or officer, ever been revoked
in this State or elsewhere? ...................... Y / N
b Has any application submitted by you for license
as private detective, private
investigator, watchguard or patrol
agency ever been denied by this State, or
any other governmental or regulatory
body or officer in this State or elsewhere? Y /N
9
Has any license or permit issued to you or applied for by you ever been
denied,
suspended or revoked by this State
or any other governmental or regulatory
body or officer in this State or
elsewhere? ..........................................................
Y / N
10 Is
there any complaint against you now pending before any department, bureau,
board, prosecuting officer, criminal
court or any other governmental or
regulatory body or officer in this
State or elsewhere? .........................................
Y / N
11 If
any answer to Questions 3 to 10 inclusive is Yes, explain fully, setting
forth
details for each such answer.
(Attach additional sheets, if necessary):
I have read the (Name of
Alarm Monitoring Organization) employee background and criminal history
release form, have signed it, and attached it herewith. If I am
hired and for as long as I continue to work for the company, if any state
or Federal agency should in future require a more current authorization
for the release of criminal background information, I agree to sign forms
needed for that purpose.
Any person making a material
misstatement on this form will be subject to immediate termination as
well as possible prosecution for perjury.
X
Applicant's Signature Date
X
Principal's Signature & Date: Date
Subscribed and sworn to
before me this
day
of
, .
Month
Year
Notary Public
Licensing Reciprocity Standard for Alarm Monitoring Organizations
APPENDIX B
AUTHORIZATION FOR
RELEASE OF PRIVATE DATA
HELD BY STATE OR FEDERAL PUBLIC SAFETY OR CRIMINAL JUSTICE
AGENCIES TO: Name of Alarm Monitoring Organization (Employer)
Applicant's Full Name:
Applicant's Address:
Immediate previous address:
Date and City of Birth:
Social Security Number:
I hereby authorize any State
and Federal agency to release to Employer any and all information and
data of every sort in its possession which relates in any manner to me
including all records evidencing convictions of any crimes and records
relating to me that are contained in any of its files, including police
reports, police memoranda and any computerized data sheets regarding any
of the above records. This authorization applies to any records
kept from the date of my birth as given above and for as long as I remain
an employee of Employer.
This Authorization is dated
this
day of
, .
Month
Year
(Signature of person granting Authorization)
Subscribed and sworn to
before me this
day
Note: This is a suggested release form to use as a of
, .
guideline for Alarm Monitoring Organizations. It is
Month
Year the responsibility of each company to verify the
appropriateness of the language to meet the requirements of the company
and the states in which it Is to be used.
NOTARY PUBLIC
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