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STATE OF MINNESOTA Board of Private Detective and Protective Agent Services 1430 Maryland Avenue East, St. Paul MN 55106 Dear License Holder, The Private Detective and Protective Agent Services Board will soon be considering license reissuance applications for the month of July 2017. The license reissuance process is noted in M.S. §326.3383, subd. 1. The return deadline is July 3, 2017. You are encouraged to send in your materials prior to that date. Failure to return all reissuance materials may result in delays, or the license may not be reissued. Timely return will allow ample time to process the application and for board review. If there are problems concerning a reissuance, you will be informed of those issues and necessary response. The board typically meets the last Tuesday of each month to consider reissuance applications for that month (check the calendar on our website for the exact date). Following that meeting, your reissued license and materials will be sent. If you should choose not to seek license reissuance please contact me. Enclosed are the materials necessary for you to complete. Please review and refer to the statutes and administrative rules when you are completing the application and other necessary paperwork. Take special note of the checklist on the application. This will help ensure all necessary items have been completed. Renewal Fee Structure: There is much confusion among license holders regarding whether or not they have ‘0’ or ‘1’ employee in calculating their renewal fee. You can read more about this once our October 2013 Meeting Minutes are posted at https://dps.mn.gov/entity/pdb/board- meetings/Pages/minutes.aspx The new renewal fee structure beginning January 1st, 2014 is: REISSUANCE Private Detective Protective Agent *0 -1 Employees $ 540.00 *0 -1 Employees $ 480.00 *2 to 10 Employees $ 710.00 *2 to 10 Employees $ 650.00 11 to 25 Employees $ 880.00 11 to 25 Employees $ 820.00 26 to 50 Employees $1,050.00 26 to 50 Employees $ 990.00 51 or more employees $1,220.00 51 or more employees $1,160.00 For the purposes of calculating the number of employees; the Board uses the following equation as provided in administrative rule: 7506.0140 FEES. Subp. 2. License reissuance fees. The fees for a reissuance of a license are set according to the number of employees. For purposes of this subpart only, an applicant shall determine the number of employees as described in items A to C. A. Count as one employee each person who regularly works an average of 30 or more hours per week performing duties as described in Minnesota Statutes, section 326.338, subdivisions 1 and 4. B. Total the annual hours worked by persons hired periodically or who regularly work less than 30 hours per week performing duties as described in Minnesota Statutes, section 326.338, subdivisions 1 and 4. Divide that total by 1500. C. Total the figures from items A and B to calculate the number of employees to use when determining the appropriate fee. NOTE: Corporate, Limited Liability Company, and Partnership license holders must include the Qualified Representative and Minnesota Manager, as well as any corporate/company officer who carries out licensed activity. PLEASE MAKE CHECKS OR MONEY ORDERS PAYABLE TO: “Private Detective and Protective Agent Services Board” Pilot Cars Certification On January 1 st , 2014 the certification of pilot car drivers with the state of Minnesota was enacted. Recent revision in the statutes state that no other certification or license is required for providing this service. If you currently have a protective agent license for the sole purpose of providing pilot car services this license is no longer required. Please contact our agency if you have any questions. Please review the following statutes and rules:

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Page 1: STATE OF MINNESOTA Board of Private Detective and ...kstp.com/kstpImages/repository/cs/files/July 2017 Corporate Renew… · The Private Detective and Protective Agent Services Board

STATE OF MINNESOTA Board of Private Detective and Protective Agent Services 1430 Maryland Avenue East, St. Paul MN 55106

Dear License Holder, The Private Detective and Protective Agent Services Board will soon be considering license reissuance applications for the month of July 2017. The license reissuance process is noted in M.S. §326.3383, subd. 1. The return deadline is July 3, 2017. You are encouraged to send in your materials prior to that date. Failure to return all reissuance materials may result in delays, or the license may not be reissued. Timely return will allow ample time to process the application and for board review. If there are problems concerning a reissuance, you will be informed of those issues and necessary response. The board typically meets the last Tuesday of each month to consider reissuance applications for that month (check the calendar on our website for the exact date). Following that meeting, your reissued license and materials will be sent. If you should choose not to seek license reissuance please contact me. Enclosed are the materials necessary for you to complete. Please review and refer to the statutes and administrative rules when you are completing the application and other necessary paperwork. Take special note of the checklist on the application. This will help ensure all necessary items have been completed. Renewal Fee Structure: There is much confusion among license holders regarding whether or not they have ‘0’ or ‘1’ employee in calculating their renewal fee. You can read more about this once our October 2013 Meeting Minutes are posted at https://dps.mn.gov/entity/pdb/board-meetings/Pages/minutes.aspx The new renewal fee structure beginning January 1st, 2014 is: REISSUANCE Private Detective Protective Agent *0 -1 Employees $ 540.00 *0 -1 Employees $ 480.00 *2 to 10 Employees $ 710.00 *2 to 10 Employees $ 650.00 11 to 25 Employees $ 880.00 11 to 25 Employees $ 820.00 26 to 50 Employees $1,050.00 26 to 50 Employees $ 990.00 51 or more employees $1,220.00 51 or more employees $1,160.00 For the purposes of calculating the number of employees; the Board uses the following equation as provided in administrative rule: 7506.0140 FEES. Subp. 2. License reissuance fees. The fees for a reissuance of a license are set according to the number of employees. For purposes of this subpart only, an applicant shall determine the number of employees as described in items A to C.

A. Count as one employee each person who regularly works an average of 30 or more hours per week performing duties as described in Minnesota Statutes, section 326.338, subdivisions 1 and 4.

B. Total the annual hours worked by persons hired periodically or who regularly work less than 30 hours per week performing duties as described in Minnesota Statutes, section 326.338, subdivisions 1 and 4. Divide that total by 1500.

C. Total the figures from items A and B to calculate the number of employees to use when determining the appropriate fee. NOTE: Corporate, Limited Liability Company, and Partnership license holders must include the Qualified Representative and Minnesota Manager, as well as any corporate/company officer who carries out licensed activity. PLEASE MAKE CHECKS OR MONEY ORDERS PAYABLE TO: “Private Detective and Protective Agent Services Board” Pilot Cars Certification On January 1st, 2014 the certification of pilot car drivers with the state of Minnesota was enacted. Recent revision in the statutes state that no other certification or license is required for providing this service. If you currently have a protective agent license for the sole purpose of providing pilot car services this license is no longer required. Please contact our agency if you have any questions. Please review the following statutes and rules:

Page 2: STATE OF MINNESOTA Board of Private Detective and ...kstp.com/kstpImages/repository/cs/files/July 2017 Corporate Renew… · The Private Detective and Protective Agent Services Board

o Minnesota Administrative Rule Chapter 7455: PILOT VEHICLE ESCORT FOR OVERDIMENSIONAL LOAD

This can be found at: https://www.revisor.mn.gov/rules/?id=7455 o Minnesota Statute: 299D.085: OVER DIMENSIONAL LOAD ESCORT DRIVER

This can be found at: https://www.revisor.mn.gov/statutes/?id=299D.085 o Another helpful link is: http://mn.gov/elicense/licenses/licensedetail.jsp?URI=tcm:29-4102&CT_URI=tcm:27-117-32 o There are training classes being provided, one being from Hennepin Technical College:

http://hennepintech.edu/customizedtraining/cts/100 Be advised, the Minnesota Board of Private Detectives and Protective Agent Services does not regulate this certification program. For more information please contact:

Minnesota Department of Public Safety (DPS), 445 Minnesota Street St. Paul, MN 55101 (651) 201-7000 | (651) 282-6555 (TTY)

Minnesota State Patrol 445 Minnesota St., Suite 130, St. Paul, MN 55101 Commercial Vehicle Section (651) 201-7100 | (651) 282-6555 (TTY

It is this agency’s goal is to reduce the number of renewals that get sent back or get delayed due to discrepancies. I am finding some common issues and want to clear these up before you send in your packet:

1. Beginning January 1st, 2014 there was a new renewal fee schedule (please see attached). When you are figuring out your fee payment only count employees that are employed in Minnesota.

2. Please make sure to complete the Workers Compensation form. Be advised this is a state required form that is audited by the Department of Labor. If you do not have any employees you must still complete the bottom portion.

3. The Board has decided that everyone must complete and sign an Affidavit of Training, even if you are an individual with no employees. Please fill in each appropriate blank on the form legibly.

4. If you took training classes that are not listed as certified by the Board these need to be pre-approved. 5. Please submit copies of your insurance certificates that pertain to the renewal period. This would include certificates that

were in effect for past 2 years. I realize that your insurance company sends our agency these items, but it would assist us greatly in expediting the renewal process if you can provide copies with your packet.

6. You do not have to return your current license certificate. It is dated and therefore inactive. You are hereby instructed to shred it.

7. Be advised that if we do not receive your packet by the first of the month in which it is due it will be marked as late. The Board may impose a penalty. If you have a situation that prohibits getting the packet in on time contact me.

8. Though I am sending you an electronic version I do need you to mail me back a hard copy. 9. If your packet is complete it will be presented at the Board meeting for Board approval. You will be notified after the Board

meeting of the status. 10. Our agency will then change your database to reflect your next renewal date which will be two years from the date of

approval. 11. We will then mail you out your new certificate.

As always, I am here to assist you with the process. It is my goal to make this process as smooth as possible and have no contingencies (delayed renewals). I am working with the Board to streamline our processes and remove the bureaucracy. Some changes take Board approval; others require legislative approval, which is a significantly longer process. One initiative I have begun is having the renewal process done online, but for now the paper application is what we are dealing with. If you run into any issues during your renewal process, have questions or expect delays, please contact me promptly at [email protected] (email preferred) or call at (651)793-2668. Please do not wait until the due date to notify us that you cannot meet the deadline. Sincerely,

Gregory J. Cook, CFE, CPP Executive Director Minnesota Board of Private Detective and Protective Agent Services [email protected] Phone: (651) 793-2668 TTY 651/282-6555

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1

STATE OF MINNESOTA BOARD OF PRIVATE DETECTIVE AND PROTECTIVE AGENT SERVICES LICENSE REISSUANCE APPLICATION: Corporation/LLC

Current License #: Expiration Date: QUALIFIED REPRESENTATIVE (QR): CHIEF EXECUTIVE OFFICER (CEO): MINNESOTA MANAGER (MM): ____________________________CHIEF FINANCIAL OFFICER (CFO): ___ (For entities located out of state) CORPORATE/LLC NAME(s): Any and all names used in association with the license must be listed here & registered with the MN Secretary of State’s Office. CORPORATE/LLC ADDRESS: ___ MN ADDRESS (if applicable):_____________________________ _________ _________________________________ CORPORATE BUSINESS PHONE: ( ) CORPORATE FAX: ( ) MINNESOTA BUSINESS PHONE: ( ) MINNESOTA FAX: ( ) (Include both Corporate/LLC and local numbers when applicable.) QUALIFIED REPRESENTATIVE EMAIL: _______________________________________________ MINNESOTA MANAGER EMAIL: $10,000 SURETY BOND COMPANY: BOND #: # OF EMPLOYEES CURRENTLY WORKING FOR THE BUSINESS AUTHORIZED UNDER THIS LICENSE: (This includes the Minnesota Manager and Qualified Representative) __________ HAVE BACKGROUND CHECKS AND CRIMINAL RECORD CHECKS BEEN PERFORMED ON ALL PERSONNEL IN THE EMPLOY OF THE LICENSED BUSINESS (including Qualified Representative, Minnesota Manager, and corporate/company officers or partners that provide licensable services)? Y N HAVE THE QUALIFIED REPRESENTATIVE, MINNESOTA MANAGER, OR CORPORATE/COMPANY OFFICER OF EMPLOYEES BEEN CONVICTED OF ANY DISQUALIFYING ACT SPECIFIED IN MINNESOTA STATUTES §326.3381, Subd. 3 (1) ? Y N If so, specify: __________________ DESCRIBE THE ROLE WHICH THE PERSON(S) LISTED AS THE QUALIFIED REPRESENTATIVE AND MINNESOTA MANAGER PLAY IN THE SUPERVISION AND MANAGEMENT OF THE LICENSED BUSINESSES (be specific): ______________________________________________________ CHECKLIST: (Please complete the following checklist by placing an X to the left of the item) All information on this form including signatures has been completed and is legible and correct. All officer positions have been filled out on the application and are correct.

Reissuance fee enclosed in the form of check or money order, payable to the MN Private Detective and Protective Agent Services Board.

Filed with the MN Secretary of State. Informed Consent Renewal completed by each individual signing the application.

A complete Affidavit of Training form as well as a separate and complete Armed Affidavit of Training form (if armed), with all forms meeting the criteria. A completed Affidavit of Employee Training is required for all renewals, this includes sole proprietors, Minnesota Managers, Qualified Representatives, and all employees. Any employee who is a Minnesota licensed peace officer is exempt from training requirements but you must provide a copy of that employee’s Minnesota peace officer license and list them on the Affidavit of Training indicating they are POST certified. No employee can carry or use a weapon (while carrying out licensable duties) without first successfully completing Board approved training.

Appropriate documentation of proof of financial responsibility for both years that fell within the license period (MS §326.3382, Subd. 3(c)). Liability insurance must be provided on an Acord 25 with the Certificate Holder listed as follows: MN Board Private Detective and Protective Agents, 1430 Maryland Ave E, St. Paul, MN 55106

Completed Worker’s Compensation Compliance form (MS §176.182). ACKNOWLEDGMENT AND VERIFICATION I affirm that all information and documentation in this reissuance application is true and correct and that I have completed each item on the checklist and filled out the checklist. I affirm that I have read MS §326.32-326.339 and Administrative Rules 7605.0100-7506.2900. Qualified Representative Signature Date____ Chief Executive Officer Signature Date____ Chief Financial Officer Signature Date____ Minnesota Manager Signature Date____ (if out of state)

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BCA FBI

1st Year

Continuing

Training Date

(MM/DD/YY)

1st Year

Continuing

Training Course

Number

2nd Year

Continuing

Training Date

(MM/DD/YY)

2nd Year

Continuing

Training Course

Number

COLUMN 1

COLUMN

2

COLUMN

3

COLUMN

4

COLUMN

5

COLUMN

6

COLUMN

7

COLUMN

8

COLUMN

9

COLUMN

10

COLUMN

11

COLUMN

12

Preassignment

Training Course

Number

Dates (MM/DD/YY) of Continuing Training and Course Numbers

Affidavit of Training

*All fields on this form are required for each employee, Minnesota Managers, and Qualified Representatives

Armed?

Yes/No

(If yes, complete

page 2)

Hire Date

(MM/DD/YY)

Employee Name (Last, First)

*Qualified Representatives and

Minnesota Managers are

considered employees

Date (MM/DD/YY) BCA

& FBI Background

Checks Completed

Date

(MM/DD/YY) ID

Card Issued

*Applicable to all

employees,

Minnesota

Managers, and

Qualified

Representatives

Date (MM/DD/YY)

Preassignment

Training Completed

*To be taken within

21 days of hire date.

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Affidavit of Training (AOT) Instructions Column A: Employee Name (Last, First)

This column is to list each employee currently employed and conducting licensable activity under your private detective or protective agent license.

All Sole Proprietors, Qualified Representatives and Minnesota Managers are to be counted as an employee and listed on the AOT. This applies even if the Qualified Representatives and/or Minnesota Managers do not reside in the state or personally operate in the state.

Column B: Hire Date (MM/DD/YY):

The Board discussed the term of hire date at a previous board meeting. Their conclusion was that “Hire Date” could also be considered their “Start Date”. This date would be the date in which the employee begins on the payroll.

Please be sure to input this date with the correct (MM/DD/YY) format. Column C & D: Date (MM/DD/YY): BCA & FBI Background Checks Completed:

Please be sure to input the correct BCA and FBI background check dates with the correct (MM/DD/YY) format.

These should be the dates the employee(s), including Sole Proprietors, Minnesota Managers and Qualified Representatives, were originally hired on in their capacity.

Column E: Date (MM/DD/YY) ID Card Issued:

Per the following Minnesota Statute, each employee, Sole Proprietor Minnesota Manager, and Qualified Representative conducting licensable activities under the private detective or protective agent license, must be issued an Identification Card. Currently, it is the responsibility of the license holder to provide these ID cards.

326.336 EMPLOYEES OF LICENSE HOLDERS. Subd. 2.Identification card.

An identification card must be issued by the license holder to each employee. The card must be in the possession of the employee to whom it is issued at all times. The identification card must contain the license holder's name, logo (if any), address or Minnesota office address, and the employee's photograph and physical description. The card must be signed by the employee and by the license holder, qualified representative, or Minnesota office manager.

Please be sure to input the correct date that each individuals’ ID cards are issued and write them in the correct (MM/DD/YY) format.

Column F: Date (MM/DD/YY) Preassignment Training Completed:

Each employee, Sole Proprietor, Qualified Representative, and Minnesota Manager is subject to completing Board Certified Preassignment training.

This training must be completed within 21 days of the employee, Sole Proprietor, Qualified Representative, and Minnesota Manager’s hire/start date per Minnesota Statute.

Please be sure to input the correct preassignment date in the correct (MM/DD/YY) format. Column G: Preassignment Training Course Number:

Each certified training course is assigned a specific course number.

After the completion of each course, a certificate of completion should be received with the specific course number.

This course number is to be kept for your records as well as placed in this column of the AOT.

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Column H: Dates (MM/DD/YY) of Continuing Training and Course Numbers 1st Year Continuing Training Date (MM/DD/YY):

Each employee, Sole Proprietor, Qualified representative, and Minnesota Manager is subject to annual certified continuing training.

This training should be taken per renewal dates rather than calendar dates. For example: August 2014 to August 2015.

Please be sure to input the correct date that each individual completed their first year of continuing training in the correct (MM/DD/YY) format.

Column I: Dates (MM/DD/YY) of Continuing Training and Course Numbers: 1st Year Continuing Training Course Number:

Please be sure to input the correct course number of the certified continuing training each individual received for their first year of the license renewal.

Column J: Dates (MM/DD/YY) of Continuing Training and Course Numbers: 2nd Year Continuing Training Date (MM/DD/YY):

Each employee, Sole Proprietor, Qualified representative, and Minnesota Manager is subject to annual certified continuing training.

This training should be taken per renewal dates rather than calendar dates. For example: August 2014 to August 2015.

Please be sure to input the correct date that each individual completed their second year of continuing training in the correct (MM/DD/YY) format.

Column K: Dates (MM/DD/YY) of Continuing Training and Course Numbers: 2nd Year Continuing Training Course Number:

Please be sure to input the correct course number of the certified continuing training each individual received for their second year of the license renewal.

Column L: Armed? Yes/No:

Please write “Yes” or “No” in this column for each employee listed on the AOT in regards to whether or not they are armed.

If you do provide armed services, please complete the additional Armed Affidavit of Training.

Please refer to the following Minnesota Statutes for the definition of “Armed”:

326.32 DEFINITIONS. Subd. 1a.Armed with a firearm.

An individual is "armed with a firearm" if at any time in the performance of the individual's duties the individual wears, carries, possesses, or has access to a firearm. Subd. 1b.Armed with a weapon.

An individual is "armed with a weapon" if at any time in the performance of the individual's duties the individual wears, carries, possesses, or has access to:

(1) a weapon other than a firearm; or (2) an immobilizing or restraining device.

Page 7: STATE OF MINNESOTA Board of Private Detective and ...kstp.com/kstpImages/repository/cs/files/July 2017 Corporate Renew… · The Private Detective and Protective Agent Services Board

BCA FBI1st Year Continuing Training Date (MM/DD/YY)

1st Year Continuing Training Course Number

2nd Year Continuing Training Date (MM/DD/YY)

2nd Year Continuing Training Course Number

License Holder Signature: _____________________________________________________________________________________________________________ Date Completed: _________________________________                                                                         This form is available on our website https://dps.mn.gov/entity/pdb, under the training area ‐ "Compliance Documents", in WORD and EXCEL formats taht will allow you to enter information and save to your computer. You may also copy this form as needed for your use.

Affidavit of TrainingLicense # ___________________          Company / License Holder Name  ___________________________________________________________________________________                                                                    Form# T‐3007    

Preassignment Training Course 

Number

Dates (MM/DD/YY) of Continuing Training and Course Numbers

* All fields on this form are required for all employees, Minnesota Managers, Qualified Representatives and Sole Proprietors

Armed?         Yes/No           

(If yes, complete page 2)

Hire Date      (MM/DD/YY)

Employee Name (Last, First)     *Qualified Representatives and 

Minnesota Managers are considered employees

Date (MM/DD/YY) BCA & FBI Background Checks 

Completed

Date (MM/DD/YY) ID Card Issued *Applicable 

to all employees, Minnesota Managers, 

and Qualified Representatives

Date (MM/DD/YY) Preassignment Training 

Completed             *To be taken within 21 

days of hire date.

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Affidavit of Armed Training

*All fields on this form are required for all armed employees, Minnesota Managers, and Qualified Representatives

Employee Name (Last, First) *Qualified Representatives and Minnesota Managers are considered employees

Weapon Type(s)

Date (MM/DD/YY) of

Initial Armed Training

Initial Armed Course

Number

Dates (MM/DD/YY) of Continuing Armed Training and Course Number

1st Year Continuing

Training Date (MM/DD/YY)

1st Year Continuing

Training Course Number

2nd Year Continuing

Training Date (MM/DD/YY)

2nd Year Continuing

Training Course

Number

COLUMN A

COLUMN B

COLUMN C

COLUMN

D

COLUMN

E

COLUMN F

COLUMN G

COLUMN H

Page 9: STATE OF MINNESOTA Board of Private Detective and ...kstp.com/kstpImages/repository/cs/files/July 2017 Corporate Renew… · The Private Detective and Protective Agent Services Board

Armed Affidavit of Training (AOT) Instructions Column A: Employee Name (Last, First)

This column is to list each armed employee currently employed and conducting licensable activity under your protective agent license.

All armed Sole Proprietors, Qualified Representatives and Minnesota Managers are to be counted as an employee and listed on the AOT. This applies even if the armed Sole Proprietors, Qualified Representatives and/or Minnesota Managers do not reside in the state or personally operate in the state.

Column B: Weapon Type(s):

Please be sure to list any and all weapons that each employee, Sole Proprietor, Qualified Representative, and Minnesota Manager carries while working under the license.

Column C: Date (MM/DD/YY) of Initial Armed Training:

Each armed employee, Sole Proprietor, Qualified Representative, and Minnesota Manager is subject to completing additional initial armed Board Certified Training along with the regular 12 hour Board Certified Preassignment Training.

Please be sure to input the correct initial armed training date in the correct (MM/DD/YY) format. Column D: Initial Armed Course Number:

Each certified training course is assigned a specific course number that should be found on their certificate as well as posted on the list of training courses on our agency’s website.

This course number is to be kept for your records as well as placed in this column of the AOT. Column E: Dates (MM/DD/YY) of Continuing Armed Training and Course Number: 1st Year Continuing Training Date (MM/DD/YY):

Each armed employee, Qualified Representative, and Minnesota Manager is subject to annual certified continuing armed training.

This training should be taken per renewal dates rather than calendar dates. For example: August 2014 to August 2015.

Please be sure to input the correct date that each individual completed their first year of continuing armed training in the correct (MM/DD/YY) format.

Column F: Dates (MM/DD/YY) of Continuing Armed Training and Course Number: 1st Year Continuing Training Date Course Number:

Please be sure to input the correct course number of the certified continuing armed training each individual received for their first year of the license renewal.

Column G: Dates (MM/DD/YY) of Continuing Armed Training and Course Number: 2nd Year Continuing Training Date (MM/DD/YY):

Each armed employee, Sole Proprietor, Qualified Representative, and Minnesota Manager is subject to annual certified continuing armed training.

This training should be taken per renewal dates rather than calendar dates. For example: August 2014 to August 2015.

Please be sure to input the correct date that each individual completed their first year of continuing armed training in the correct (MM/DD/YY) format.

Column H: Dates (MM/DD/YY) of Continuing Armed Training and Course Number: 2nd Year Continuing Training Date Course Number:

Please be sure to input the correct course number of the certified continuing armed training each individual received for their second year of the license renewal.

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1st Year Continuing 

Training Date (MM/DD/YY)

1st Year Continuing 

Training Course Number

2nd Year Continuing 

Training Date (MM/DD/YY)

2nd Year Continuing 

Training Course Number

License # _______________         Company / License Holder Name __________________________________________________________________                                                              FORM# T‐3008       

License Holder Signature: _______________________________________________________________________ Date Completed: _________________________________                             This form is available on our website https://dps.mn.gov/entity/pdb, under the training area ‐ "Compliance Documents", in WORD and EXCEL formats that will allow you to enter information and save to 

your computer. You may also copy this form as needed for your use.

Affidavit of Armed Training

Dates (MM/DD/YY) of Continuing Armed Training and Course Number

* All fields on this form are required for all armed employees, Minnesota Managers, and Qualified Representatives

Employee Name (Last, First)      *Qualified Representatives and 

Minnesota Managers are considered employees

Weapon Type(s)Date (MM/DD/YY) of Initial Armed 

Training 

Initial Armed Course Number

Hire/Start Date in Armed  Capacity (MM/DD/YY)           

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Informed Consent Renewal

Company Name: _________________________________________________________

Street Address: __________________________________________________________

City: _____________________________________ State: ____ Zip code: ___________

Date: ___________________________

Last Name (please print): ________________________________________________

First Name (please print): ________________________________________________

Middle (full) (please print): ________________________________________________

Maiden, Alias or Former (please print): _____________________________________

Date of Birth: ____________________ Sex (M or F): ______________

Month/Day/Year

Pursuant to MN Statute 326.3381 I authorize the Minnesota Bureau of Criminal

Apprehension to disclose all criminal history record information to the Minnesota Board

of Private Detectives and Protective Agents for the purpose of licensure renewal.

The expiration of this authorization shall be one year from the date of my signature.

Signature ________________________________ Date _____________

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CERTIFICATE OF COMPLIANCE MINNESOTA WORKERS’ COMPENSATION LAW

Minnesota Statutes §176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers’ compensation insurance coverage requirement of M.S. Chapter 176. The information required is: the name of the insurance company, the policy number, and dates of coverage or the permit to self-insure. This information will be collected by the licensing agency and retained in their files. This information is required by law. Licenses and permits to operate a business may not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this information is not provided or is falsely stated, it may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. Insurance Company: (NOT the insurance agent)

Policy Number: Dates of Coverage: to

-- or --

I have no employees I am self-insured (include permit to self-insure) I have no employees who are covered by the workers’ compensation law (these

include: spouse, parent, children and certain farm employees) I certify that the information provided above is accurate and complete and that a valid workers’ compensation policy will be kept in effect at all times as required by law. Name: Last, First Middle -- Please type or print. Doing Business As (dba): Business name if different than your name – please type or print. Business Address: Street Address

City, State, ZIP

Phone: Please include area code.

Signature: Date: