
Texas Department of Public Safety
•
MUST USE MOST CURRENT FORM
PRIVATE SECURITY
Regulatory Services Division
•
PRINT CLEARLY I N BLACK INK
EXAMPLE:
www.dps.texas.gov
•
MAKE SURE ENTIRE CIRCLE IS FI LLED
Yes
No
APPLICATION AND FEE SUBMISSION FORM
REQUEST I NFORMATI ON
I understand this form is used for auditing purposes and MUST be submitted with
the proper application(s) and fee(s).
Yes
No
I understand if this form is NOT attached with the supporting documents and / or if
the form is incorrect, the entire package will be returned.
Yes
No
THE ABOVE SPACE I S RESERVED FOR OFFI CE USE ONLY
Company
Name
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
information, as applicable. Companies do not need to include a Social Security Number (SSN), unless registration is for an individual. Effective October 27, 2014, the 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 that is produced.
Enclosed in this package are the follow ing:
Check #
SSN
(FOR I NDIVIDUALS ONLY)
I ndividual OR Company Name
Type of
Registration
Transaction Fee $
Ex. 1010 000-00-0000 John E. Doe Non-Commissioned Original $38
Ex. 200200 n/a Just A Sample Security & Alarm Company Company Renewal $412
Total # of Checks Enclosed Total Amount Enclosed
SI GNER
Signer
Last Name
Signer
First Name
Business
Phone
Business
Email
I verify 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