ࡱ> #` +bjbj 9D ||||4h4 hL0FFF        $2 h u~a|~~ ||FF &&&~|FF &~ &&6JF PJj 'N$ 0 ,,r2,\,U2AH&]!   ~~~~dzS|||||| Please TYPE Part 1 PERSONAL INFORMATION: Last NameFirst NameMiddle NameMaiden / All Other NamesSocial Security NumberBirth DateCity/State of BirthCitizenshipEmail Address 1:Web Site: Email Address 2:Home TelephonePersonal Fax NumberPersonal Cell NumberPersonal PagerOffice TelephoneOffice Fax NumberOffice Cell NumberOffice Pager ADDRESSES CURRENT THROUGH LAST TEN YEARS Attach additional Typed Information on Spread sheet if necessary Number & StreetCityStateZIPDRIVER LICENSE INFO: State: License # Exp_ _/_ _/_ _ _ Please provide a Full MVR, Complete History, Certified copy of your driving history record, MVR, covering all years and all states in which you held a drivers license during that time. Have you ever had a Drivers License in another State or Foreign Country? If so please provide the following: State: Years _ _ _ _ to _ _ _ _ License Number ___________________________ Misdemeanor Offenses such as DUI, DWAI ___________________________________________________________________________________ State: Years _ _ _ _ to _ _ _ _ License Number ___________________________ Misdemeanor Offenses such as DUI, DWAI ___________________________________________________________________________________ State: Years _ _ _ _ to _ _ _ _ License Number ___________________________ Misdemeanor Offenses such as DUI, DWAI ___________________________________________________________________________________ Part 2 Experience Verification & Membership Level I am applying for the following membership level:  SENIOR (More than 6000 Hours of Experience) . ASSOCIATE (2000 TO 6000 Hours of Experience) . APPRENTICE (Less than 2000 Hours of Experience . AFFILIATE (Out of State) . Please fill in below spreadsheet detailing your hours per year. You must provide contact information of the person (s) who could provide an affidavit to verify your experience information. See Below Example. Experience must be verifiable, otherwise it will not be accepted, and may be cause for Denial of Application. YearFraction of year1950 hours in a Year# of HoursDescription of Investigation Experience,=Supervisor Verification PhoneVerification name address20000.40Police Patrol - Patrol Activities are not considered investigation. 20000.6x 19501170Investigation duties, transferred to detective division from Patrol. Investigation crime scenes. Houston PDSGT Bill Bass713 343-2259Houston PD, 120 W 23rd Ave, SW, Houston, TX20011x 19501950Houston PD Detective Bureau full time Investigations assigned to Crimes against personsDET SGT Thomas713 242-3000 X 124Houston PD, 120 W 23rd Ave, SW, Houston, TX20020.3x 1950585 Hired by Dade County DA's Office, in September 2002. Felony case investigationBill Williams, DA305 667-2323District Attorney's 242 west 23rd street, Miami, FL20030.7x19501365Dade County DA's Office,. Full time preparation of Felony cases thru trial process, witness interviewsDarnell Smith, District Attorney305 667-2000District Attorney's 242 west 23rd street, Miami, FL20041x 19501950Dade County DA's Office,. Full time preparation of Felony cases thru trial process, witness interviewsDarnell Smith, District Attorney305 667-2000District Attorney's 242 west 23rd street, Miami, FLTotal Hours7020TOTAL Experience Hours Guidelines: Experience must be Relevant, and Verifiable. Academic Courses are not considered Experience Verification Individuals may be asked to complete a Affidavit of Verification under Oath. Experience Spreadsheet YearFraction of a Year1950 hours in a year# of HoursDescription of Investigation ExperienceSupervisor Verification Phone Verification Name & AddressTOTAL HOURS Part 3 EDUCATION: The following information must include K-12, College, or Technical Schools, including any investigative training or other professional qualification courses. Please provide a copy of a certificate or other official documentation attesting to the completion or graduation. Attach additional documentation as required. School City/StateTypeDegree SchoolCity/StateTypeDegree SchoolCity/StateTypeDegree SchoolCity/StateTypeDegree SchoolCity/StateTypeDegree SchoolCity/StateTypeDegree SchoolCity/StateTypeDegree SchoolCity/StateTypeDegree Part 4 EMPLOYMENT HISTORY All RELEVANT EMPLOYMENT ALL YEARS: All Employment for Last Seven (7) years must be included Note: If work with any of these employers involves investigative experience that may be considered in order to establish the membership level you are requesting, please attached a description of that experience. Note all military Experience and attach DD: 214 form for documentation. Detail each military Service. Branch of Service Dates of Service MOS: Rank: Discharge type: Honorable/General/ Dishonorable: EmployerAddressCity, State, ZIPStarting DateEnding DateContact PersonTitleTelephone Type of Work:Reason For Leaving: EmployerAddressCity, State, ZIPStarting DateEnding DateContact PersonTitleTelephone Type of Work:Reason For Leaving: EmployerAddressCity, State, ZIPStarting DateEnding DateContact PersonTitleTelephone Type of Work:Reason For Leaving: EmployerAddressCity, State, ZIPStarting DateEnding DateContact PersonTitleTelephone Type of Work:Reason For Leaving:EmployerAddressCity, State, ZIPStarting DateEnding DateContact PersonTitleTelephone Type of Work:Reason For Leaving:EmployerAddressCity, State, ZIPStarting DateEnding DateContact PersonTitleTelephone Type of Work:Reason For Leaving: EmployerAddressCity, State, ZIPStarting DateEnding DateContact PersonTitleTelephone Type of Work:Reason For Leaving: EmployerAddressCity, State, ZIPStarting DateEnding DateContact PersonTitleTelephone Type of Work:Reason For Leaving: Part 5: CRIMINAL HISTORY Felony/Misdemeanor/ Summons, including US District Courts, UCMJ, and Foreign Courts. All Criminal Matters for all years must be listed. Failure to list a Criminal case may result in Denial of Application. If you have been a resident of Colorado at any time during the last seven years, please obtain and provide with this application a copy of a statewide arrest record report available on-line via the Colorado Bureau of Investigation. You may obtain the report at www.cbirecordscheck.com. There is a fee that may be paid via credit card. You may review your court history at  HYPERLINK "http://www.cocourts.com" www.cocourts.com for $6.00 and attach the Detail Printouts. If, at any time during the last seven years you were a resident of another state, please provide a copy of that states equivalent to the CBI report. You must use the official state agency designated for the purpose of obtaining such reports. You may not use a commercial service, unless it is designated by the state as the official source of such reports. You may be required to provide a coy of offense report/and or Court file Any report thus obtained must be dated within 30 days of the date of this application. Name (s) Case # & Type Cty/Dist Date Filed: Closed/Open Party Type Court    Brown, Sam Use additional Page if necessary2007 CR 0031.45 Restraining Order 04/04/1995 ClosedDefendant Jeffco District Ct., Golden, CODetails: Name (s) Case # & Type Cty/Dist Date Filed: Closed/Open Defendant Court    Details: Name (s) Case # & Type Cty/Dist Date Filed: Closed/Open Defendant Court    Details: Name (s) Case # & Type Cty/Dist Date Filed: Closed/Open Defendant Court    Details: Part 6: CIVIL COURT HISTORY All Civil Court Cases, Municipal, District or Superior Courts, Foreign Courts. Includes Small Claims, Money Demands, Probate, Domestic or Family Courts. Attach Additional Documentation as Necessary You are required to provide us with any information regarding any civil court or administrative action to which you were or are a party (not just a Witness.) This includes state, county, municipal, and justice courts or their equivalents. This also includes Federal civil, criminal, and bankruptcy matters. Note: You must report case information NO MATTER WHAT THE OUTCOME. If necessary, attach additional information. You may review your court history at  HYPERLINK "http://www.cocourts.com" www.cocourts.com for $6.00 and attach the Detail Printouts. Name Case Filed Status Party TypeCounty     Sam James Brown 1990 CV 2432-101 07/04/1997  OpenDefendant  Denver District Court Details: Name Case Filed Status Party County     Details: Name Case Filed Status Party County     Details: Name Case Filed Status Party County     Details: Attach Additional Pages as required Part 7: PROFESSIONAL LICENSING INFORMATION: If you hold or previously held a professional license of any type in any state, please detail that information, as follows, and provide a copy of that license along with this application: License TypeLicense NumberIssuing StateStatusWas this license ever Suspended, Revoked, Terminated for any reason other than expiration: Yes . No . If Yes, Explain: License TypeLicense NumberIssuing StateStatusWas this license ever Suspended, Revoked, Terminated for any reason other than expiration: Yes . No . If Yes, Explain: License TypeLicense NumberIssuing StateStatusWas this license ever Suspended, Revoked, Terminated for any reason other than expiration: Yes . No . If Yes, Explain: PROFESSIONAL AFFILIATIONS/MEMBERSHIP: List any current/active professional affiliations or memberships, whether they are investigative related or not: Part 8: CERTIFICATION: I/ declare under penalty of perjury, under the laws of the State of Colorado, that all information contained on this application for PPIAC Membership and any accompanying documents are true and correct, with full knowledge that all statements made in this form are subject to review and that ANY FALSE OR DISHONEST ANSWER TO ANY QUESTION MAY BE GROUNDS FOR DENIAL OR SUBSEQUENT REVOCATION OF PPIAC MEMBERSHIP. Signature Date: Printed Name (s): DOB: SSN: If accepted into membership, I agree to abide by the By-Laws and Code of Ethics of the PPIAC. Signature Date Printed Name (s): DOB: SSN: WAIVER: I hereby give my full consent to the professional Private Investigators Association of Colorado, its officers, members, or agents to investigate the information provided in this application and to inquire into my reputation, character, and fitness to include criminal and civil records, past or present employers, schools, colleges, or universities, and professional associations and organizations. I also hereby release the above named organizations, officers, members, or agents from liability, claims, or injuries (implied or actual) in matters arising from such an investigation. A copy of this waiver shall be as valid as the original. Signature Date Printed Name (s): DOB: SSN: 9. CHECK LIST: This application must be accompanied by the following: A fully completed application on this approved form. Complete employment information or all relevant employment, to include at a very minimum all employment for last 7 years. If you are basing experience on employment, that employment must be listed. Complete documentation of investigative work experience in hours. Complete explanations of any and all criminal & civil cases in all state, federal or foreign courts, or UCMJ. Certified full MVR from every state where you have had a drivers license. Criminal history report from CBI, or repository for criminal records of every state in which you have lived.. Fee of $175 for applicants who have been continual residents of Colorado for all of the last seven years. Fee of $225 for applicants who have been residents of Colorado less than seven years. Fee of $225 for Affiliate, out of state applicants. (Check or money order made payable to the PPIAC) One digital color image/photograph, 1 wide by 1.2 high (minimum 300 dpi, email to dana@dh-llc.us). Copies of any records, certificates, documents of any type required by this application form. Email Application & Digital Image to:  HYPERLINK "mailto:dana@dh-llc.us" dana@dh-llc.us. Email Signature with digital certificate may be accepted same as original signature Mail with Check Payable to PPIAC to: Dana Hoffman Dont forget to Sign Application. 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PPIAC ROSTER INFORMATION: Please provide the following information which will be used for the PPIAC Roster and will be included on the PPIAC Web Site at www.ppiac.org. 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