Form DPS-166-C "Application for License as Professional Bondsman" - Connecticut

What Is Form DPS-166-C?

This is a legal form that was released by the Connecticut Department of Emergency Services and Public Protection - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2011;
  • The latest edition provided by the Connecticut Department of Emergency Services and Public Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DPS-166-C by clicking the link below or browse more documents and templates provided by the Connecticut Department of Emergency Services and Public Protection.

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Download Form DPS-166-C "Application for License as Professional Bondsman" - Connecticut

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State of Connecticut
Department of Emergency Services and Public Protection
Division of State Police
Special Licensing and Firearms Unit
APPLICATION FOR LICENSE AS PROFESSIONAL BONDSMAN
INSTRUCTIONS TO APPLICANTS
For Office use only:
1.
Complete by printing or typing in all entries, using black ink only.
Date of Application:
____/____/____
2.
If a “Yes” is checked use plain 81/2 x 11 paper for additional space.
3.
Include a $ 200.00 certified check or money order for Bondsman
License #:
license, made payable to Treasurer, State of Connecticut.
4.
Include 2 X 2 full face color passport type photo with blue background
Name of Applicant:
Last Name
First Name
MI
List all other names by which you have been known
( Maiden Name, Aliases, Nicknames, etc.):
Residential Address
(Do not use a P.O. Box Number):
Number
Street
City/Town
State
ZIP Code
Bondsman Business Name (If any)
Business Phone #
Business Address Mandatory
(for public information use, P.O. Box number acceptable)
Number
Street
City/Town
State
ZIP Code
Date of Birth
Race
Sex
Height
Weight
Hair Color
Eyes Color
Home Telephone
(
)
Place of Birth
Social Security Number
Operator License Number/Issuing State
(City/Town/Country)
CITIZENSHIP
Are you a citizen of the United States?
YES
NO
(If Naturalized, state when and where):
MEDICAL HISTORY
Have you ever been committed to or confined in a Hospital for a Mental Illness?
YES
NO
(If Yes, explain):
Have you ever received care or treatment for any mental, psychiatric, psychological illness or disorder?
YES
NO
(
If Yes, explain):
Have you been discharged from custody, within the past twenty (20) years, after having been
found not guilty of a crime by reason of mental disease or defect ? (If Yes, explain):
YES
NO
EMPLOYMENT HISTORY
Provide the following information about your present employer:
(If you are not employed, provide information of your most recent employer)
Company Name
Address (Street, City, State, ZIP Code)
Supervisor Name
Telephone No.
Are you retired or separated from a Local or State Police Department?
YES
NO
(If Yes, a letter of discharge from the employer describing the length of service, duties and date of retirement or separation must be attached)
YES
NO
Are you currently applying or interviewing for a Federal, State or Local Police Department. (If yes, whom and where)
Are you presently vested with Police Powers?
YES
NO
MILITARY SERVICE
Were you ever discharged from the Armed Forces of the United States with a less than Honorable Discharge?
(I
f
YES
NO
Yes, explain. If you performed military service attach a copy of your Form DD-214 or NGB-22 must be attached
State of Connecticut
Department of Emergency Services and Public Protection
Division of State Police
Special Licensing and Firearms Unit
APPLICATION FOR LICENSE AS PROFESSIONAL BONDSMAN
INSTRUCTIONS TO APPLICANTS
For Office use only:
1.
Complete by printing or typing in all entries, using black ink only.
Date of Application:
____/____/____
2.
If a “Yes” is checked use plain 81/2 x 11 paper for additional space.
3.
Include a $ 200.00 certified check or money order for Bondsman
License #:
license, made payable to Treasurer, State of Connecticut.
4.
Include 2 X 2 full face color passport type photo with blue background
Name of Applicant:
Last Name
First Name
MI
List all other names by which you have been known
( Maiden Name, Aliases, Nicknames, etc.):
Residential Address
(Do not use a P.O. Box Number):
Number
Street
City/Town
State
ZIP Code
Bondsman Business Name (If any)
Business Phone #
Business Address Mandatory
(for public information use, P.O. Box number acceptable)
Number
Street
City/Town
State
ZIP Code
Date of Birth
Race
Sex
Height
Weight
Hair Color
Eyes Color
Home Telephone
(
)
Place of Birth
Social Security Number
Operator License Number/Issuing State
(City/Town/Country)
CITIZENSHIP
Are you a citizen of the United States?
YES
NO
(If Naturalized, state when and where):
MEDICAL HISTORY
Have you ever been committed to or confined in a Hospital for a Mental Illness?
YES
NO
(If Yes, explain):
Have you ever received care or treatment for any mental, psychiatric, psychological illness or disorder?
YES
NO
(
If Yes, explain):
Have you been discharged from custody, within the past twenty (20) years, after having been
found not guilty of a crime by reason of mental disease or defect ? (If Yes, explain):
YES
NO
EMPLOYMENT HISTORY
Provide the following information about your present employer:
(If you are not employed, provide information of your most recent employer)
Company Name
Address (Street, City, State, ZIP Code)
Supervisor Name
Telephone No.
Are you retired or separated from a Local or State Police Department?
YES
NO
(If Yes, a letter of discharge from the employer describing the length of service, duties and date of retirement or separation must be attached)
YES
NO
Are you currently applying or interviewing for a Federal, State or Local Police Department. (If yes, whom and where)
Are you presently vested with Police Powers?
YES
NO
MILITARY SERVICE
Were you ever discharged from the Armed Forces of the United States with a less than Honorable Discharge?
(I
f
YES
NO
Yes, explain. If you performed military service attach a copy of your Form DD-214 or NGB-22 must be attached
CRIMINAL ACTIVITY HISTORY
Have you ever been convicted in any court of any crime?
YES
NO
(If Yes, list all convictions, including all charges, locations, dates of arrests and dispositions using additional sheets of paper if additional space is
required):
Have you ever been arrested for any incident that involved violence, moral turpitude, or for use, Sale, or
YES
NO
Possession of Illegal Drugs or Narcotics, or Driving While Under the Influence of Alcohol and/or Drugs?
(If Yes, list all convictions, charges, locations, dates of arrests and dispositions using additional sheets of paper if additional space is required)
Are you currently on Probation, Parole, a Work Release Program, In an Alcohol and/or Drug Rehabilitation
YES
NO
Program or Currently Released on Personal Recognizance (WPTA) or Bond for a Pending Court Case?
(If Yes, explain):
Are you now the subject of a Restraining Order, or Protective Order issued by a court, in a case involving
YES
NO
the use attempted use or Threatened use of Physical Force Against Another Person?
(If Yes, explain)
MOTOR VEHICLE HISTORY
Have you ever been arrested or issued an infraction complaint or summons for a motor vehicle charge? (If Yes,
explain list all arrest)
YES
NO
With regard to criminal history information arising from the State of Connecticut’s jurisdiction: You are not required to disclose the existence of any arrest,
criminal charge or conviction, the records of which have been erased pursuant to Connecticut General Statutes sections 46b-146, 54-76o or 54-142a. With
regard to criminal history information arising from jurisdictions other than the State of Connecticut: You are not required to disclose the existence of any
arrest, criminal charge or conviction, the records of which have been erased pursuant to the law of the other jurisdiction. Additionally, you are not required
to disclose the existence of an arrest arising from another jurisdiction if you are permitted under the law of the other jurisdiction to swear under oath that
you have never been arrested.
EDUCATION
List the highest-level Certificate, Diploma or Degree Received. i.e., High School, G.E.D., B. A., etc.
(Attach a copy of transcripts, diplomas, or certificates claimed)
Within the past five years you shall have successfully completed a Criminal Justice Program Courses
YES
NO
consisting of not less than 20 semester hours of studies related to the use of force, arrest, search and
seizure and constitutional law?
(If Yes, attach supporting documentation)
List any other training appropriate for this application
(Attach separate sheet of paper as necessary
LICENSE AND PERMIT INFORMATION
Do you have a Bondsman, Private Detective, or Security license
YES
NO
? If Yes, #
Do you have a Conn. State Pistol Permit?
YES
NO
If Yes, #
Do you have a Conn. Security Officer’s Firearms Permit "Blue Card”?
YES
NO
If Yes, #
Do you intend to apply for a Bail Enforcement Agent Firearms Permit?
YES
NO
If yes, #
Have you ever had any of your licenses or permits denied, suspended or revoked?
YES
NO
(If Yes, explain details on an attached sheet of paper)
Must have a sound financial history with sufficient assets of $15,000 minimum to be approved.
I THE SIGNER OF THE FOREGOING APPLICATION AND THE ATTACHED FINANCIAL STATEMENT, UNDERSTANDS, UNDER
THE PENALTIES OF GIVING A FALSE STATEMENT TO A POLICE OFFICER, THAT THE ANSWERS TO THE ABOVE QUESTIONS
ARE TRUE AND CORRECT. I ALSO UNDERSTAND THAT FALSE STATEMENTS CONTAINED IN THIS APPLICATION ARE
GROUNDS FOR THIS APPLICATION NOT TO BE APPROVED AND FOR THE LICENSE APPLIED FOR NOT TO BE ISSUED. MY
SIGNATURE BELOW ATTESTS TO THE ACCURACY OF ALL MY ANSWERS AND TO THE TRUTH OF ALL OF THE
INFORMATION INCLUDED IN THIS APPLICATION.
Signature of Applicant:
Date signed:
/
/
The signer of the foregoing application personally appeared before me and made oath to the truth of the
, 20
_____
matters contained herein; this
day of
_____
Notary Public, Justice of the Peace, Commissioner of Superior Court
My commission expires:
DPS-166-c (Rev. 7/11)
An Affirmative Action/Equal Opportunity Employer
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