The Texas PSB 20 form is an application used for registering individuals seeking to work in various security roles under the Texas Department of Public Safety. This form is essential for those applying for positions such as non-commissioned security officers, commissioned security officers, or personal protection officers. Proper completion and submission of this form are crucial for compliance with state regulations governing private security services.
The Texas PSB 20 form is an essential document for individuals seeking to register as non-commissioned or commissioned security officers, as well as personal protection officers in Texas. This form is specifically designed for those applying under a Governmental Letter of Authority (GLOA) exemption. It requires applicants to provide personal information, including their name, social security number, and details about their employment. Additionally, the form includes a section for background information, where applicants must disclose any felony or misdemeanor convictions, military discharge status, and mental health evaluations. It's important to note that submitting fingerprints is a critical part of the application process, and applicants must choose how they will provide this information. Payment details are also included, emphasizing that all fees are non-refundable and non-transferable. Lastly, the form must be completed accurately and submitted to the Texas Department of Public Safety, as any discrepancies can lead to delays or denials in the application process.
Texas Department of Public Safety Regulatory Services Division
www.txdps.state.tx.us
• MUST USE MOST CURREN T
PRIVATE SECURITY
FORM
• KEY I N OR PRI N T CLEARLY I N BLACK I NK
EXAMPLE:
• MAKE SURE ENTI RE CI RCLE I S FI LLED
Yes
No
GOVERNMENTAL LETTER OF AUTHORITY (GLOA) EXEMPTION APPLICATION
REGI STRATI ON I NFORMATI ON
THE ABOVE SPACE I S RESERVED FOF OFFI CE USE ONLY
Type of Registration: (CHOOSE ONE)
Type of Application: (CHOOSE ONE)
Governmental Letter of Authority Non-Commissioned Security Officer
Original Application
Governmental Letter of Authority Commissioned Security Officer
Renewal Application
Governmental Letter of Authority Personal Protection Officer
APPLI CANT I NFORMATI ON
Gov Letter of
Gov Letter of Authority
Authority Name
License No.
Applicant Social
-
Driver License
DL/ I D
Security Number
I D Card
State:
No.
Applicant Last Name
Home Address
First Name
Middle Name
Suffix
(I f Any)
City
State
ZI P
Home
(
)
(2- Digit Code)
Phone
Date of Birth
Place
(CI TY)
(STATE)
(COUNTRY)
/
(MM/ DD/ YYYY)
of Birth
Gender
Male
Female
Eyes
1.
Blue
2.
Brown
3.
Gray
4.
Hazel
5.
Green
6.
Black
Height
Ft.
I n.
Hair
Red
Blonde
Bald
Race
Weight
Lbs.
White
Hispanic
American
Asian
Other
I ndian
_______
List any alias you have used:
Describe
Your Duties:
SUPPLEMENTAL I NFORMATI ON (REQUI RED WI TH ORI GI NAL APPLI CATI ON ONLY – DOES NOT APPLY TO RENEWALS)
Regarding submitting Fingerprints: (CHOOSE ONLY ONE)
I am submitting two (2) classifiable, Board approved fingerprint cards along with the $ 25 FBI classification fee.
I am submitting the $ 25 FBI classification fee. My fingerprints were submitted electronically and my signed I BT FAST receipt is attached as proof with this application.
I am a Peace Officer (or Retired Peace Officer) alternatively submitting a PSB-00 (Peace Officer Fingerprint Waiver) form with this application, instead of FBI fingerprint cards.
PAYMENT I NFORMATI ON
Original Registration Application Fee OR Renew al Fee: $0
I am submitting the appropriate fee(s) with this application by mail.
(Note: Payment must be in the form of a cashier’s check, money order or company check.)
No
* I f yes, a PSB-50 form m ust be submitted with this application.
I understand all fees submitted to Private Security are non- refundable and non transferable. I n accordance with Administrative Rule Yes
35.77, I have 90 days from the date the application is received by the Department to submit all required documentation, supplemental information and/ or fees or this application will be abandoned and I will be required to reapply.
PSB-20 (Rev. 06/ 2011)
Page 1 of 2
Applicant Name
Social
Security No.
BACKGROUND I NFORMATI ON – PART I ( ALL APPLI CANTS)
1.
Have you ever been convicted, in any jurisdiction, of a felony
* I f yes, has it been LESS than ten (10) years since
completing
your
level offense?
sent ence or probat ionary period?
2.
Have you ever been convicted, in any jurisdiction, of a Class A or
* I f yes, has it been LESS than five (5) years since completing your sent ence
equivalent misdemeanor?
or probat ionary period?
3.
Have you, within the past 5 years, been convicted, in any jurisdiction, of a Class B misdemeanor or equivalent offense?
4.
Are you currently charged with, or under indictment for, a felony, or Class A misdemeanor?
5.
Are you currently charged with a Class B misdemeanor?
6.
Have you ever been found by a court to be incompetent by reason of mental defect?
* I f yes, and
you
received a dishonorable discharge, a bad conduct discharge, or
an
other
than
7.
Were you discharged from the military?
honorable discharge, from Armed Forces, then you must submit a copy of your DD- 214 .
8.
Are you required to register as a sex offender, in the state of Texas or any other state?
9.
Federal law prohibits the Bureau from issuing a license to anyone
I f yes, you must submit documentation of your naturalization or a copy
who is ineligible to work in the U.S. Are you a non- citizen?
of your permanent resident card.
BACKGROUND I NFORMATI ON – PART I I ( COMMI SSI ONED SECURI TY OFFI CERS & PERSONAL PROTECTI ON OFFI CERS ONLY)
10.
Are you currently restricted under a court protective order or subject to a restraining or affecting the spousal relationship, other than a
restraining order solely affecting property interests, including any court order restraining your conduct as to an intimate partner?
11.
Have you been diagnosed by a license physician as suffering from a psychiatric disorder or condition that causes or is likely to cause substantial
impairment in judgment, mood, perception, impulse control, or intellectual ability? (See Occupations Code §1702.163 (d), (e) & (f).)
12.
Have you been convicted in any court of a misdemeanor offense involving domestic violence?
13.
Are you an unlawful user of a controlled substance or addicted to any controlled substances?
BACKGROUND I NFORMATI ON – PART I I I ( ALL APPLI CANTS)
14.
I understand that, any pending charges or conviction referred to in Background I nformation Parts I and I I above require the submission of the
appropriate court documentation, with this application. Failure to report an arrest or conviction, later found by a fingerprint search, may result
in denial or revocation of a license based solely on the material misstatement of fact in this application.
15.
I acknowledge that I have review ed the eligibility criteria of Occupations Code §1702.113 and the definition of ‘conviction’ provided in §1702.371
and Administrative Rule §35.1. I also acknowledge that I have review ed the disqualifying offenses listed in Administrative Rules 35.42 and 35.46.
EMPLOYER I NFORMATI ON (TO BE COMPLETED BY QUALI FI ED MANAGER, MANAGER’S DESI GNEE OR OWNER)
I hereby certify that the above applicant began employment in a position that requires this registration with my company on:
Applicant’s Date of Employment (MM/ DD/ YYYY)
I am requesting that the above applicant be issued a registration with my company as my employee.
Manager or Manager’s Designee Printed Last Name
Printed First Name
I verify that the information provided is true and correct, and I understand that this is an official Government record and that any false statement made on this document or any other supplement provided to the Department may result in criminal prosecution.
Applicant Signature________________________________________________
Date____ / ____ / ________
Manager or Manager’s Designee Signature________________________________________________
This form and attachments can be forwarded by mail to:
Texas Department of Public Safety
Private Security MSC 02 42
PO Box 15999
Austin, TX 7 8761 - 5999
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