Private Investigator License Application

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Private Investigator
License Application
Send this completed form with a check or money order, payable to the
Department of Licensing, to:
Public Protection Services
Department of Licensing
PO Box 35001
Seattle, WA 98124-3401
For validation only 001-070-299-0012
Telephone: (360) 664-6611
This is an application for:
New unarmed applicant – $200
Armed endorsement – $100 (in addition to $200 fee if new applicant)
Transfer/Rehire – $25 (in addition to renewal fee if due)
Renewal – $175
Late renewal – $200
Certified trainer endorsement renewal – $15 (in addition to renewal fee)
Applicant information
TYPE or PRINT Name (Last, First, Middle)
Date of birth
Applicant's residential street address
City
State
(Area code) Home telephone number
Social Security number
Citizenship
U.S. citizen ZIP code
Resident alien
Gender
Used identification. Kept on file.
42 USC 405(c)(2)(C)
Male Female
Business information
Business name
Agency UBI number
Agency license expiration date
Business street address as it appears on the license
City
State
(Area code) Business telephone number
ZIP code
(Area code) Fax number
Certification of preassignment testing/training (New applicants only)
Name of certified trainer
License number of certified trainer
Expiration date
Certification
I hereby certify under penalty of perjury under the laws of the state of Washington, that the above named applicant has
successfully completed the preassignment training and testing requirements as outlined in WAC 308-17-300. Incorrect
answers were reviewed with the applicant and the test results have been verified and signed by me.
Date and place signed
X
Certified trainer signs here when completed.
Signature of certified trainer
Firearms certification course (New armed applicants only)
Armed private investigators attend an eight-hour firearms certification course certified by the Criminal Justice Training
Commission (CJTC), telephone (206) 835-7300. When you complete the firearms training, they will issue a certificate.
We cannot issue you an armed license until we receive your firearms certificate. RCW 18.170.040(c)
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Signature required on next page
Applicant personal data
1. If you have ever been convicted of a crime, including juvenile convictions, you must provide complete information
about your convictions and include copies of your court records. A determination of your eligibility cannot be made
until all documentation is received and a complete criminal history record check has been completed.
• Do not include traffic violations for driving under the influence, driving while suspended, or reckless driving.
• If you are not sure of your record, please do the research before you apply. Application fees are non-refundable.
What were you
convicted of?
Date
Name of court
City and state
Misdemeanor, gross
misdemeanor, or felony?
1.
2.
To show additional convictions, attach pages.
2. Is there a criminal complaint, accusation, or information presently pending against you or are
you currently under indictment in this state, any other state, by the federal government, or any
other jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
3. Has any professional or occupational license, certification, or permit held by you been fined,
suspended, revoked, refused or denied in this state, any other state, by the federal government
or any other jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Yes No
Applicant authorization and certification
Do you authorize all organizations and government agencies (local, state, federal, or foreign) to
release any information, files, or records requested to this Department to process your application? . . . . I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
Date and place signed
X
Applicant signs here when completed.
Applicant signature
Providing false information in this application may be cause for the denial, suspension, or revocation of your private
investigator license in the state of Washington.
PI-689-012 (R/5/14)WA Page 2 of 4 We are committed to providing equal access to our services.
If you need accommodation, please call (360) 664-6611 or TTY (360) 664-0116.
This information is to be provided to licensing applicants who are required to submit a fingerprint card. It is also available
at www. dol.wa.gov.
Federal Bureau of Investigation Privacy Act Statement
Authority: The FBI’s acquisition, preservation, and exchange of information requested by this form is generally authorized
under 28 USC 534. Depending on the nature of your application, supplemental authorities include numerous federal statutes,
hundreds of state statutes pursuant to Public Law 92-544, presidential executive orders, regulations and/or orders of the
Attorney General of the United States, or other authorized authorities. Examples include, but are not limited to: 5 USC 9101;
Pub.L. 94-29; Pub.L. 101-64; and Executive Orders 10450 and 12968. Providing the requested information is voluntary;
however, failure to furnish the information may affect timely completion or approval of your application.
Social Security Account Number (SSAN): Your SSAN is needed to keep records accurate because other people may
have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is
responsible for informing you whether disclosure is mandatory or voluntary, by what statutory or other authority your SSAN
is solicited, and what uses will be made of it. Executive Order 9397 also asks federal agencies to use this number to help
identify individuals in agency records.
Principal purpose: Certain determinations, such as employment, security, licensing, and adoption, may be predicated on
fingerprint-based checks. Your fingerprints and other information contained on (and along with) this form may be submitted
to the requesting agency, the agency conducting the application investigation, and/or FBI for the purpose of comparing the
submitted information to available records in order to identify other information that may be pertinent to the application. During
the processing of this application, and for as long hereafter as may be relevant to the activity for which this application is
being submitted, the FBI may disclose any potentially pertinent information to the requesting agency and/or to the agency
conducting the investigation. The FBI may also retain the submitted information in the FBI’s permanent collection of fingerprints
and related information, where it will be subject to comparisons against other submissions received by the FBI. Depending
on the nature of your application, the requesting agency and/or the agency conducting the application investigation may
also retain fingerprints and other submitted information for other authorized purposes of such agency (ies).
Routine uses: The fingerprints and information reported on this form may be disclosed pursuant to your consent, and
may also be disclosed by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5 USC 552a(b))
and all applicable routine uses as may be published at any time in the Federal Register, including routine uses for the FBI
fingerprint Identification Records System (Justice/FBI-009) and the FBI’s Blanket Routine Uses (Justice/FBI-BRU). Routine
uses include, but are not limited to, disclosures to: appropriate governmental authorities responsible for civil or criminal law
enforcement, counterintelligence, national security or public safety matters to which the information may be relevant; to state
and local governmental agencies and nongovernmental entities for application processing as authorized by federal and state
legislation, executive order, or regulation, including employment, security, licensing and adoption checks; and as otherwise
authorized by law, treaty, executive order, regulation, or other lawful authority. If other agencies are involved in processing
this application, they may have additional routine uses.
Additional information: The requesting agency and/or the agency conducting the application/investigation will provide you
additional information pertinent to the specific circumstances of this application, which may include identification of other
authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in the
Federal Executive Branch has also published notice in the Federal Register describing any system(s) of records in which
that agency may also maintain your records, including the authorities, purposes, and routine uses for the system(s).
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Noncriminal Justice Applicant’s Privacy Rights
As an applicant who is subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose
(such as an application for a job or license, an immigration or naturalization matter, security clearance, or adoption), you
have certain rights which are discussed below:
• You must be provided written notification1 that your fingerprints will be used to check the criminal history records of the FBI.
• If you have a criminal history record, the officials making a determination of your suitability for the job, license, or other
benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record.
• The officials must advise you that the procedures for obtaining a change, correction, or updating of your criminal history
record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34.
• If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record
(or decline to do so) before the officials deny you the job, license, or other benefit based on information in the criminal
history record.2
You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized
purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure
or standard established by the National Crime Prevention and Privacy Compact Council.3
If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible
challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by
submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at http://www.fbi.gov/
about-us/cjis/background-checks.
If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your
challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge
directly to the FBI. The FBI will then forward your challenge to the agency that contributed the questioned information and
request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency,
the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that
agency. (See 28 CFR 16.30 through 16.34.)
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