Fill and Sign the Dd Form 2752 Nsep Service Agreement for Scholarship and Fellowship Awards 20140310 Draft

DCJS - Private Security Services Section PSS_IA: Initial Instructor Certification Application - Instructions Minimum eligibility requirements: 1. Be a minimum of 18 years of age. 2. Have a high school diploma or equivalent (GED). 3. Have successfully completed a DCJS instructor development course within the three years immediately preceding the date of the application, or submits a partial training exemption application for an instructor development course that meets or exceeds standards established by the department; or successful completion of an approved DCJS instructor development program longer than three years prior to the date of application, and has provided documented instruction during the three years immediately preceding, or has provided instruction in a related field at an institution of higher learning. 4. Have a minimum of (i) three years management or supervisory experience with a private security services business or with any federal, military police, state, county or municipal law-enforcement agency, or in a related field; or (ii) five years general experience in a private security services business, with a federal, state or local law-enforcement agency, or in a related field; or (iii) have a minimum of one year experience as an instructor or teacher at an accredited educational institution or agency in the subject matter for which certification is requested, or in a related field. 5. Be a United States citizen or legal resident alien of the United States. Additional requirements, documentation required: 1. In order to process your application, you must submit all required documentation. Applications received without the required documentation will be returned. DCJS does not retain documentation. Please do not write in "on file" or "attached to another application"; all relevant documentation must accompany the application requiring it. 2. In addition to meeting the minimum requirements for eligibility, you must have both training and experience - or direct instructor experience - in each category for which you seek certification (i.e. - a former law enforcement officer may be eligible for SCOP but not for electronic security subjects). Prior to submitting this application, you may wish to review the regulatory requirements which can be found here: http://www.dcjs.virginia.gov/pss/documents/administrativeCode/section100.pdf 3. If you are applying for alternative credit or a partial exemption for instructor development training, you should wait until that application has been processed prior to submitting this application. If you plan to attend the DCJS Instructor Development course, this application will be provided at the class. If you do not yet have the training required, this application cannot be processed. 4. A fingerprint processing application and fingerprint card must have been received within the 90 days immediately preceding this application. If you have not submitted fingerprints within the past 90 days, please also submit a form PSS_FP along with the application and fee. 5. Application fees are non-refundable. Please ensure that you meet the requirements fully as outlined in the Regulations and this informational sheet prior to submitting this application. 01/07 Page 1 of 4 PSS_IA Adding firearms categories on this application: 1. You must first meet all instructor requirements in order to be eligible for firearms instructor certification. You may request these categories with your initial application provided you have met all additional requirements as above. If you do not meet all requirements for instructor certification, you will not be eligible for firearms instruction certification. 2. Whether or not you apply to instruct all actions of weapons, the Regulations require that you provide documentation on all three actions (revolver, semi-automatic handgun, and shotgun) with a score of 85% or better with each. Documentation of required qualification must be complete and include range/agency information, instructor's signature, date, (must have been during previous 12 months) and weapon type/action/caliber with score. 3. You must provide official documentation of successful completion of a firearms instructor development course designed specifically for law enforcement or private security completed within the past 3 years. If the training course was completed longer than 3 years ago, you must also provide documentation of having provided firearms instruction in a formal setting during the past 3 years. If you have questions regarding instructor eligibility or other requirements for this application, please visit our website or contact the Private Security Services Section at 804-786-4700. 01/07 Page 2 of 4 PSS_IA I NITIAL I NSTRUCTOR A PPLICATION COMMONWEALTH OF VIRGINIA Department of Criminal Justice Services Private Security Services Section P.O. Box 1300 th Richmond, VA 23218 Phone #: (804) 786-4700; Fax #: (804) 786-6344 Website: http://www.dcjs.virginia.gov/pss Status Hotline: (804) 786-1132 or 1-877-9STATUS Form Code: PSS_IA Fee Code: 150 Application Fee - $100.00 Check or Money Order payable to: Treasurer, Commonwealth of Virginia Application Fees are Non-Refundable NOTE: Prior to completing this application, please review the attached instructions. Failure to submit required documentation or to fully complete this application may result in delays in processing time. 1. Applicant Name: Last Name First Name 2. Social Security or DCJS ID #: 3. Mailing Address: 4. Telephone: Residence Number and Street MI Date of Birth City/Town m m/dd/yy State Business 5. May the Department provide information via an e-mail address? Zip Fax Yes No 6. E-Mail Address: 7. Are you currently instructing at a Private Security Training School? If yes, School Name: 8. Yes No DCJS ID# 88- Have you submitted fingerprints to this Department for a National and State Criminal History Check within the past 90 days? YES NO 9. If NO, please complete and submit a Fingerprint application form PSS_FP, one (1) fingerprint card and $50.00 processing fee for a national and state criminal history check or this application cannot be processed. Have you committed any act or omission which resulted in a license, certification or registration being suspended, revoked, not renewed or being otherwise disciplined in any local, state (including Virginia) or national regulatory body? NO YES If YES, attach copies of any correspondence or documentation related to this matter to include the name of the jurisdiction in which it took place, the license number and the name of the business/individual involved. Provide an explanation of the events, including a description of the disciplinary proceeding and the type of sanctions that were imposed. 10. Please indicate when you successfully completed your entry-level instructor development training*: ________________________________ With DCJS date completed Received partial training exemption and completed additional training required _____________ date completed *NOTE: This application cannot be processed until this training has been credited. 01/07 Page 3 of 4 PSS_IA 11. Instruction Subject(s) Requested: (Check each that applies) Security Officer Core Subjects (01) Private Investigator (02) Armored Car Personnel (03) Security Canine Handler (04) Armed Security Officer Arrest Authority (05) Special Conservator of the Peace (06) Electronic Security Subjects (30) Personal Protection Specialist (32) Electronic Security Technician (35) Central Station Dispatcher (38) Electronic Security Sales Rep. (39) Bail Bondsman (40) Bail Enforcement Agent (44) 12. Firearms Instruction Category(s) Requested: (Check each that applies) Handgun (07) Shotgun (08) Advanced Handgun (09) 13. Checklist of attached official, third-party documentation I have enclosed: (REQUIRED) Three years supervisory or five years general experience in private security, law enforcement or related (Required) Certificate of completion of instructor development training (Required) Category specific training and experience (Required for each category checked off above) Certificate of completion of firearms instructor development training (if applicable) Signed/dated range sheets for semi-automatic, revolver AND shotgun 85% or better Please note: Applications that are submitted without required documentation will be returned. I, the undersigned, certify that all information contained on this application is true and correct to the best of my knowledge and I have not omitted any pertinent information. I understand that any misrepresentation, falsification or omission of pertinent information may be cause for denial and may result in criminal charges. I understand that I am responsible for maintaining full compliance with Virginia Code Section 9.1.138 through 9.1-150 and the Regulations Relating to Private Security Services 6VAC 20-171. Applicant's Signature 01/07 Date: Page 4 of 4 PSS_IA