
PSB-20 (Rev. 06/ 2011) Page 2 of 2 FORM
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
level offense?
Yes
No
* If yes, has it been LESS than ten ( 10) years since completing your
sent ence or probationary period?
Yes
No
2. Have you ever been convicted, in any jurisdiction, of a Class A or
equivalent misdemeanor?
Yes
No
* I f yes, has it been LESS than five (5) years since completing your sent ence
or probationary period?
Yes
No
3. Have you, within the past 5 years, been convicted, in any jurisdiction, of a Class B misdemeanor or equivalent offense?
Yes
No
4. Are you currently charged with, or under indictment for, a felony, or Class A misdemeanor?
Yes
No
5. Are you currently charged with a Class B misdemeanor?
Yes
No
6. Have you ever been found by a court to be incompetent by reason of mental defect?
Yes
No
7. Were you discharged from the military?
Yes
No
* I f yes,
and you received a dishonorable discharge, a bad conduct discharge, or an other than
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?
Yes
No
9. Federal law prohibits the Bureau from issuing a license to anyone
who is ineligible to work in the U.S. Are you a non-citizen?
Yes
No
I f yes, you must submit documentation of your naturalization or a copy
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?
Yes
No
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).)
Yes
No
12. Have you been convicted in any court of a misdemeanor offense involving domestic violence?
Yes
No
13. Are you an unlawful user of a controlled substance or addicted to any controlled substances?
Yes
No
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 II 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.
Yes
No
15. I acknowledge that I have reviewed 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.
Yes
No
(TO BE COMPLETED BY QUALIFI 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________________________________________________ Date____ / ____ / ________
This form and attachments can be forwarded by mail to:
Texas Department of Public Safety
Private Security MSC 0242
PO Box 15999
Austin, TX 78761-5999