Student Application

MEMBER APPLICATION

Applicant Information

Year last active

First Name

Last Name

Date Of Birth

Professional Information

Agency Name

Business Address

City

State

Zip

Business Phone

Fax

County

Industry Licensure

Type of License(s) Held

Private Detective

Private Detective Agency

Private Security Contractor

Private Security Contractor Agency

Please provide license(s) numbers.

Private Detective Individual License Number (# 115-)

Private Detective Agency License Number (# 117-)

Private Security Contractor Individual License Number (# 119-)

Private Security Contractor Agency License Number (# 122-)

Date Associated With Above

List State Disciplinary Action Taken Against You/agency (If yes to above, please explain here)

Contact Information

Home Address

City

State

Zip

Home Phone

Contact Information

List Previous Employment or Business Experience past Five Years

List Specialties You Would like Listed in Membership Directory

Business Website

Business Email

I Certify That, to the Best of My Knowledge, the Facts Contained Herein Are True and Complete. I Understand That the Information Supplied Will Be Investigated for Truthfulness and That, If Accepted, Falsified Statements on this Application Shall Be Grounds for Expulsion. I Authorize the Investigation of All Statements Contained Herein and Prior Employer’s Listed Are to Cooperate in Giving Any and All Information Concerning My Previous Employment along with Any Pertinent Information They May Have, Personal or Otherwise, and I Release All Parties from Any Liability for Any Damages That May Result from Them Furnishing Same to the Associated Detectives of Illinois, Inc.