MARYLANDSTATEPOLICE
Date of Appli cation:04/01/2O14
LigensingDivisionApplication
Pleaseread this entire
honoryour individual
the instructions
listed
Division'saddress
completed
The
sectionsand
completethe
will NOTbe
entry formats
bmit the i
Livescan Receipt #: 14652200007
application.Attachedis the applicationand formsneededto
completethe attachedapplicationin strictaccordance
with
will be returned.Submitall applications
to the Licensing
informationpageswith your application.Processing
a properly
investigate.
electroniccompletion.The form containshidden featureswith
based on the application types selected by the user. You must
before printing to sign and submit to tlE LicensingDivision.This application
format. Follow all instructionsand error
as many
have strict
of the user to accurately complete the application.
?
Allapplicants
apffig for MULTIPLE
Licenses,
Registrations,
Certifications,
Member,asa
the following
mentsas
CorporateOfficer,and for HandgunPermitsissuedunderthe authorityof th
application.Checkall licenses
that the applicantwishesto
instructed
in
includingappropriate
mustbe2" x2"
darkgl
"der
. Photographs
aken
days.Computergeneratedphotographsare
NOTE:Forms
ANT NOTEON FINGERPRINT
Alloriginal
appli
fingerprint
submissions.
Renewal
appl
onlyrequireFBIflngerprint
/fequireFBIandCJ15
submissions.
ntsmustbe submitted
by wayof anElectronic
Fingerprintl
Centerauthorized
by the
Maryland
Department
of Public
Correctional
with fingerprints
submittedby way
Electronic
of an
Fingerprint
Centerwill require
Policefor the applicationonly - Do
not includepaymentfor
processingGenter.
an
Theconfirmation
Processing
Cen
ustbeattached
applicationto facilitate
cornerof this a
cornerof the application
accountcontaining
ut tl
cksor
funds,
froma Maryland
State
i i n t h e tlper
on. Staplethe
(typedor handwritten)in the
let
hn the r/
mEtE payableto the MarylandStatlfulice
stateresidents
applg for a Handgun
Pen[qt
electronicfingerprint
center.E
locationspleasevisit
APPLICANTS
PLFASE
VISITTHEMARYLAND
OUT.OF.STATE
In thecaseof multiple
d istinctcertificationas
ts
; two photographsare
(Example:
each
Handgun
and foui (4)photos.The feestotal
DetectiveRegistrant
for
checks;one for 57S.OO
Fingerprint Processing
processingfee.
5 for the PrivateDetectigRegileti
Li
1111
(4 1 0 )
MSPForm29-01(Rev.12/2012)
for each
Private
two
cost to process
Submitall applications
Referto the certitications and
fees accompany this
RADDITIONALFINGERPRINT
State
Div
)
pages to ensure all required documentsand
Page1of1l
MARYLANDSTATEPOLICE
Date of Appfi cation:04 101/2014
LicensingDivisionApplication
LivescanReceipt#: 14652200OO7
HandgunPermitFeesrequiredby
Original-$
nd StatePoliceper statute:
Subseq
Renewal-S
Retired
Additional
1.Owner
within a
hasa
*
EftlerYourLi\rdgan
receivedfor
fromyour
in detail
and valid
3.
4. Former
you haveresignedor
suchasa letterfrom your agency,and a letterfrom your agencyindicatingyou left in good standing.Additional
may apply.
requirements
Police& RailroadPoliceCommissions:All
Guard/Special
applicantswho areemployedas
5. PrivateDetective/Security
SpecialPolice,and RailroadPolice,must submita certificationof qualification
PrivateDetectiVes,
SecurityGUards,
with a handgunfrom a MarylandStatePoliceCertifiedHandgunlnstructoron an MSPform.A copyof the form
ownershipof weapon,and locationwherethe weaponwill be
lettersupporting"good and substantialreasons,"
maintainedis alsorequired.fl-hisform can be obtainedfrom your employer).
supported
Theremust be documentedevidenceof recentthreats,robberies,and/orassaults,
Protection:
6. Personal
by officialpolicereportsor notarizedstatementsfrom witnesses.
Private Detectives/SecurityGuard Agency Licenseand CorporateOfficer(s)StatePolice:
Feesrequired
by theMaryland
not incorporated
NewAgencyPrivateInvestigator
5200.00
not
incorporated
Guard
NewAgencySecurity
$200.00
incorporated
Investigator
NewAgencyPrivate
S375.00
Guardincorporated
NewAgencySecurity
5375.00
(whensubmitted
together)
agencies
not incorporated
Detective
NewSecurity
GuardandPrivate
5375,00
(whensubmitted
together)
incorporated
Detective
agencies
NewSecurity
GuardandPrivate
S750.00
officersneednot applyuntilthecompanyhasbeenapproved)
Corporate
officersfeeS0(Corporate
bytheMaryland
StatePolicefor completion.
aremailedto the business
Applications
Note:Renewal
required:
documents
Additional
officers
of thecorporation.
andminutes
of lastmeetingappointing
of Incorporation
1. A copyof theArticles
thatthecorporation
andTaxation
certifying
of Assessment
Department
2.A copyof the receiptfromthe Maryland
in Maryland.
to do business
asa foreigncorporation
hasregistered
namingthe proper
Serviceform
andthe BoardResolution
mustsubmita Consentto
firmsor corporations
3.Foreign
packet,callforinformotion.
officerto executeit. Notincludedin application
Policy
Liability
Insurance
officers),
a copyof the General
corporate
Note:lf youemployfive(5)or morepeople,(notincluding
(onemilliondollars)
to thisapplication.
isrequired
to beattached
of S1,000,000
Private DetectiveRegistrationFeesrequiredby the MarylandStatePolice:
- 515.00fee
PrivateDetectiveRegistrant
Renewal"510.00
MSPForm29-01(Rev.12/2012)
Page2otll
MARYLANDSTATEPOLICE
Dateof Application:04/01/2014
LivescanReceipt#: 14652200007
LicensingDivisionApplication
SecurityGuardCertification- 4
Ar*
'""Ti:::l,yJH#[]ff
:"ill"
i:'ff;,F- 112?
reelt
fRenewat-slo.oo
F-tU
\*.
)
SecuritySystemsAgency Licenseand Agency Firm Member(s)MarylandCompanies- original:
1. A copyof the Articlesof Incorporationif applicable.
2. GeneralLiabilityInsurancePolicyfor at least$50,000.
3. Copiesof certifications
of any specialized
trainingrelatedto SecuritySystemssales,serviceand installation.
4. FeesRequired:
- S115.50
Individual
Licensee
AgencyFirmMembers- 50
AgencyRenewal- S100
AgencyFirm
(Corporate
officersheednot apply
- original:
Out-of-State
Companies
1.A copyofthe Licenseand
2.General
Liability
Insurance
3. Copiesof certificationsof
4. FeesRequired:
licensee
Individual
511
officersneed not
\n\zt-11k/
N\oNiJ,,
)or
SecuritySystems
(Monitor,5alesperson,
Technicianand
Feesrequired
State
bytheMaryland
- 515
Registration
Security
System
RenewalS15.00
Additional
required:
documents
Includecopiesof certifications
of
K^urct:
service,and installation.
fu{q$,.
;i\.ft\ry
service,and installation.
Out of StateRegistrationfor
(Mustbe reciprocal
with
information:
andpersons
havingaccess
to circumventional
Technician
Asa Monitor,
Salesperson,
(2)
with background
checkeverytwo years).
Maryland
issuedby the reciprocal
state.
Attacha copyof the License
/ Registration
FeesRequired:
- S15.00
(doesnot includebackground
checkfee).
Registration
Out-of-State
SpecialPoliceand RailroadPoliceCommissionsFeesRequired:
- 5100.00fee
SpecialPoliceCommission
SpecialPoliceRenewal-560.00
- S160.00
fee
RailroadPoliceCommission
Agenciesof the Stateof Maryland Exempt from the application fee, however, required to submit payment to
authorized electronic fingerprint processingcenter.
MSPForm29-01(Rev.12/2012)
Page3ofll
MARYLANDSTATEPOLICE
Dateof Appli cation:04101/ 20'l4
LicensingDivisionApplication
Livescan Receipt #: 14652200007
BulletproofBodyArmorMarylandlawmandates
that all personswith a priorconviction
prohibitedfrom using,possessing,
or purchasi
\[t9
"DNne-t
'ffir,t{l
2.
pol
ATTENTION:
Beforeyouuse,
whileusing,
^rakd{
$$r9*wfiilf
qtil(EfI t^rl,^[
**rnk
S,9\$'
ProvidingFalseor MisleadingInformationMay LeadTo Your Arrest
\
MSPForm29-01(Rev.12/2012)
Page4ofl1
MARYLANDSTATEPOLICE
Date of Appfi cation:04/O1/2014
LicensingDivisionApplication
-7 X Original
I
Renewal
Livescan Receipt #: 1465220O007
f] Subsequent
one or moreof the followinglicenses
for which this applicationis intendedto serye:
f] PrivateDetectiveCertification I
I
I
PrivateDetectiveAgency
ffi SecurityGuardCertification I
Security
Systems
Agency
Systems
Technician I HandgunPgtif ,z-a,
I Security
F-(Z)
Railroad
Police
Commission I Special
Police
Commission
Thisapplication
isbeingsubmitted
bya(n):ffi Firm
I
FirmMember
Security
GuardAgency
BodyArmor
I Bulletproof
f] Individual
1.Applicant'sName
Last:
2.StreetAddress:
. PhoneNumbers:
Email:
License
6. Driver's
7. Height:
Areyoua UnitedStates
Tfil((k'-.. r
Hor\gi:l
nincw^l
Ycuft{Quor{
A
Answer all of the following
circumstances,and/or
with this application
includingthe date,
to
necessary
9. Haveyou everbeen served
[Yes ilNo
10.Haveyou everbeenARRESTED
for a violationof any criminallaw?
[Yes
with a violationof any criminallaw?
11. Haveyou everbeenCHARGED
[Yes ilNo
MSPForm29-01(Rev.12/2012)
[No
Page5of1l
MARYLANDSTATEPOLICE
Date of Appfi cation:04/01/2014
LicensingDivisionApplication
LivescanReceipt#: 14652200O07
12.Haveyou ever been CONVICTED
of a violation of any criminallaw?
[Yes
13.Haveyou everbeenservedwith a criminalsummons?
flYes ilNo
14.Areyoucurrentlyon paroleor probationor mandatory
supervision?
[Yes ilNo
15.Haveyou everbeenconfinedor committed,includingvolu
a mentalinstitution
or hospitalfor treatmentof a mentaldisorderor
16.Are you addictedto, or
17.Areyou addictedto or have
[rsw'(
18.Areyoucurrentlybeing
dangerous
substances?
19, Haveyoueverbeenemployedasa
oholism?
|'Kne
[No
[Yes ilNo
[Yes ilNo
flYes ilNo
,Ntgs'
20. Hasyour handgunpermit,license,
jurisdiction
everbeendenied,
suspended,
21. Haveyou ever beena member of the United StatesArmed Forces?lf so,attacha copy of DD-214/
Dischargepapers.
MSPForm29-01(Rev.12/2012)
[Yes
[No
[Yes
[No
[Yei-
[No
[Yes ilNo
Page6ofl1
MARYLANDSTATEPOLICE
Date of Application:04/01/2014
LicensingDivisionApplication
LivescanReceipt#: 14652200O07
End Date
StartDate
(MM/DD/YYYY) (MM/DD/YYYY)
Address:
Employer
Fositionm6Dutie$
ReafiErGaving
Sufr./isoE Name:
ht
il(\rr${5'
I^qL
C
J
IIL''
IY
r \eart
MSPForm29-01(Rev.12/2012)
End Date
StartDate
(MM/DD/YYYY) (MM/DD/YYYY)
PageTof 11
MARYLANDSTATEPOLICE
Date of Appfi cation:04/01/20 14
LicensingDivisionApplication
Livescan Receipt#: 14652200007
any investigative
experience
or activities
Service,MilitaryService,PrivateDetective,and any
municipal,county,stateor federalpoliceforce.(Referto Title 13,Section13-303,Title 19,Section19-303for the experience
of the individualand licensee):
T) accordingto COMAR
What isthe TradeNameof your businessas
18.04.02.01?
WhatistheTradeNameor
Business
Occupations
and
Whatisyourpositionor title in
application:
thislicense
Principal Office Location:
e
,vr{
fi"?o'\c
meet the requirementsof
in connectionwith
gtNL
Zip Code:
Address:
Branch Office Locations: Toaddor
Address:
City:
Address:
City:
Zip Code:
State:
Zip Code:
takenwithin30
head& shoulderfull face,no hat,no darkglasses)
lightbackground,
of applicantOwo2" x 2" square,
Attachphotographs
generated.
Can
be
computer
preceding
filing
of
this
application.
the
days
You MUSTattachphotographsto this applicationbeforesubmission.
MSPForm29-01(Rev.12/2012)
Page8of11
MARYLANDSTATEPOLICE
Date of Appfi cation:04/01/2O14
LicensingDivisionApplication
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LrNESl:
MARYLANDSTATEPOLICE
Date of Appli cation:04/ 01/20 14
Livescan Receipt #: 14652200007
LicensingDivisionApplication
Pursuantof the provisionsof MarylandLaw,submit the namesof at least3 reputablecitizenswho have known you, the applicant,for
more than two (2)years,and are not related in any way to you, the applicant.
Email:
Full Name:
ResidenceAddress:
Nameof Employer:
Residence
Phone:
Phone:
Employer's
'
CellularTelephone:
Address:
Residence
Nameof Employer:
Phone:
Residence
Address:
Residence
Nameof Employer:
Phone:
Residence
Residence
Address:
@rtY
, .,
. rrrr( b(
N\
Nameof Employer:
Phone:
Residence
MSPForm29-01(Rev.12/2012)
P a g e1 0o f 11
MARYLANDSTATEPOLICE
Date of Appli cation:04/01/ 2014
LivescanReceipt#: 14652200007
LicensingDivisionApplication
Date of Birth:
Address
so.6i5.curityNum6t-
do herebyauthorizea reviewand full disclosureof all records,or any part thereof,concerningmyselfbylto any duly authorizedagent of
the Departmentof StatePolice,whetherthe saidrecordsarepublicor private,and includingthosewhich may be deemedto be of a
privilegedor confidentialnatureconcerningthis applicant.The intentionof this authorizationisto provideinformation,whichwill be
utilized,for investigativeresourcesmaterialfor the purposeof processingthis application.
I authorizethe full and completedisclosure
of the recordsof educationalinstitutions,
financialor creditinstitutions,
and the recordsof
commercialor retailmercantileestablishments
and retailcreditagencies;
medicaland psychiatric
consultationand/ortreatment,
includingthosehospitals,
public
clinics,privatepractitioners,
the U.S.Veterans'Administration,
and all militaryand psychiatric
facilities;
utilitycompanies;
employmentand pre-employmentrecordsincludingbackgroundinvestigations
reports,the resultsof polygraph
examinations,
efficiencyratings,complaintsor grievances
filed by or againstme;of complaintsof a civilnaturemadeby or againstme,for
the internalpurposesof the LicensingDivision,Departmentof the StatePolice.
A photocopyof this release
form will be validasan originalhereof,eventhough the saidphotocopydoesnot containan originalwriting
of my signature.
hisagentsand/oremployees,
I agreeto indemnifyand hold harmlessthe personto whom this requestis presented,
the Secretary
and the
Departmentof the StatePoliceand the Stateof Maryland,from and againstall claims,damages,lossesand expenses,
including
reasonableattorneys'feesarisingout of or by reasonof complyingwith this request.
Signature
\
I do herebydeclareand affirmunder
informati
the bestof myknowledge,
to supplyanyadditionalinformati
FORDENIALOFTHEAPPLICATION
IMPRISONMENT
NOTEXCEEDING
1
arning:Any personwho willingly
MSPForm29-01(Rev.12/2012)
t
Inn
Asgl
-lttfn
r
Pagel1of11
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