Texas Department of Public Safety Regulatory Services Division
www.dps.texas.gov
APPLICATION AND FEE SUBMISSION FORM
• MUST USE MOST CURREN T FORM |
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PRIVATE SECURITY |
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• PRI N T CLEARLY I N BLACK I NK |
EXAMPLE: |
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• MAKE SURE ENTI RE CI RCLE I S FI LLED |
Yes |
No |
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REQUEST I NFORMATI ON
I understand this form is used for auditing purposes and MUST be submitted with |
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the proper application(s) and fee(s) . |
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I understand if this form is NOT attached with the supporting documents and / or if |
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the form is incorrect, the entire package will be returned. |
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Company |
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Name |
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THE ABOVE SPACE I S RESERVED FOR OFFI CE USE ONLY
Company License
Number
PAYMENT I NFORMATI ON
Note: Form examples for an individual and a company are noted in the first two shaded rows of the table below. Fill in each column for your individual(s) and / or company informat ion, as applicable. Companies do not need to include a Social Security Number ( SSN), unless registration is for an individual. Effective October 27 , 2014 , t he Private Security Program will implement Administrative Rule 35.131(b), which requires the collection of a $5 fee for each laminated pocket card. This applies to each new, renewed or duplicate card t hat is produced.
Enclosed in this package are the follow ing:
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Check # |
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SSN |
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I ndividual OR Company Name |
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Type of |
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Transaction |
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Fee $ |
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(FOR I NDI VI DUALS ONLY) |
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Registration |
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Ex. 1010 |
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000-00-0000 |
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John E. Doe |
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Non-Commissioned |
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Original |
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$38 |
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Ex. 200200 |
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n/ a |
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Just A Sample Security & Alarm Company |
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Company |
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Renewal |
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$412 |
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Total # of Checks Enclosed
SI GNER
Signer Last Name
Business Phone
Signer First Name
Business Email
Iverify the information provided is true and correct, and I understand this is an official government record and any false statement made on this document or any other supplement provided to DPS may result in criminal prosecution.
Signature________________________________________________ Date_______________
This form and attachments can be forwarded by mail to:
Texas Department of Public Safety
Private Security MSC 0242
P.O. Box 15999
Austin, Texas 78761 - 5999
PSB-50 (Rev.10/ 2014) |
FORM |