BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR

DEPARTMENT OF CONSUMER AFFAIRS

BUREAU OF SECURITY AND INVESTIGATIVE SERVICES
P.O. Box 989002, West Sacramento, CA 95798-9002
P (916) 322-4000 | P (800) 952-5210 | F (916) 575-7290 | www.bsis.ca.gov

PERSONAL IDENTIFICATION FORM

ALARM COMPANY OPERATOR, PRINCIPALS, CORPORATE OFFICERS, MANAGING
MEMBERS, AND ALARM COMPANY QUALIFIED MANAGER

DO NOT LIVE SCAN UNTIL YOU HAVE SUBMITTED YOUR APPLICATION

Each person listed on the Alarm Company Operator Application for License (Form 31D-4) as an owner, partner, corporate
officer, managing member, and qualified manager of the business must complete and submit this form. This form is also to be
completed for any change in corporate officer, managing member, or qualified manager after the license is issued. A corporate
officer includes the chief executive officer, secretary, chief financial officer and any other officer who will be active in the
business.
This information is requested pursuant to California Business and Professions Code sections 480, 7593.1, 7593.2, 7593.3,
7593.4, and Labor Code section 432.7 and will be used to determine eligibility for licensure. All information is necessary, and if
not provided, the application may be rejected.
Have you served or are currently serving in the United States military? Yes* No
*In order to assist veterans in their transition from military service to civilian employment, BSIS has implemented the
Veterans Come First Program which offers priority services to veteran applicants. Disclosure of military service is
voluntary and participation in the program is optional. If you choose to use the Veteran’s Come First Program, check
the military status box and submit proof of military service (e.g. DD-214, DD-256, V-MET record, military orders,
military I.D., etc.) along with your application.

REFUGEE, ASYLEE, OR SPECIAL IMMIGRANT VISA HOLDER APPLICANTS

Business and Professions Code section 135.4 provides that the Bureau must expedite, and may assist, the initial licensure
process for certain applicants described below. This does not apply to applicants whose business is structured as a
partnership, corporation, or limited liability company.
☐ Check this box if any of the following statements apply to you:
• You were admitted to the United States as a refugee pursuant to section 1157 of title 8 of the United States Code;
• You were granted asylum by the Secretary of Homeland Security or the United States Attorney General pursuant to
section 1158 of title 8 of the United States Code; or,
• You have a special immigrant visa and were granted a status pursuant to section 1244 of Public Law 110-181, Public
Law 109-163, or section 602(b) of title VI of division F of Public Law 111-8, relating to Iraqi and Afghan
translators/interpreters or those who worked for or on behalf of the United States government.
Disclosure is voluntary. If you checked the box above you must attach evidence/documentation of your status as a
refugee, asylee, or special immigrant visa holder. Failure to do so may result in application review delays.

ACCEPTABLE EVIDENCE/DOCUMENTATION
• Form I-94, Arrival/Departure Record, with an admission class code such as “RE” (Refugee) or “AY” (Asylee) or other
information designating the person a refugee or asylee.
• Special immigrant visa that includes the visa category of “SI” or “SQ.”
• Permanent Resident Card (Form I-551), commonly known as a “Green Card,” with a category designation indicating
that the person was admitted as a refugee or asylee.
• An order from a court of competent jurisdiction or other documentary evidence that provides reasonable assurance that
the applicant qualifies for expedited licensure.

12 31D-9 (Rev. 01/2022)

PLEASE TYPE OR PRINT CLEARLY
1. This application is for a: 2. A change in an existing license:
Alarm Company Operator License Corporate Officer Managing Member
Alarm Company Operator Qualified Manager Qualified Manager Other_____________

3. Name of Qualified Manager (Please Print)

4. Business Name 5. License Number (if licensed)

6. Full Name Last First Middle

7. Social Security Number or Individual Taxpayer Identification Number (Mandatory) 8. Date of Birth (Mo/Day/Yr)

9. Residence Address – Number and Street City State Zip Code

10. Telephone Number (Include Area Code) 11. Email Address (optional)
Residence Business
12. YOUR POSITION WITH BUSINESS: (Check all that apply)
OWNER QUALIFIED MANAGER
PARTNER OFFICER ___________________________
MANAGING MEMBER OFFICE HELD

13. Have you ever applied for or received a license or registration from the Department of YES
Consumer Affairs, the Department of Professional and Vocational Standards, Bureau of Private NO
Investigators and Adjusters, the Collection Agency Licensing Bureau, the Bureau of Collection
and Investigative Services, or the Bureau of Security and Investigative Services?

YES
14. Have you or any partnership or corporation of which you were a member or officer had any
license denied, suspended or revoked by any state, territory, or governmental agency? NO

YES
15. Have you ever used a name other than your present legal name? NO
IMPORTANT: If you answered “YES” to any of the preceding questions, attach a supplementary
statement giving a complete and detailed explanation, including dates, names used, license numbers,
reasons, etc.

13 31D-9 (Rev. 01/2022)

16. EMPLOYMENT HISTORY: Your past five-year employment history must be shown. List most recent experience first. Qualified managers
must list two years of qualifying experience and attach their completed Qualifying Experience forms for any experience used to qualify for the
license examination. If additional space is needed, attach a separate sheet.
NAME OF EMPLOYER TELEPHONE NUMBER
(INCLUDE AREA CODE)

ADDRESS: NUMBER STREET CITY STATE ZIP CODE

YOUR POSITION TITLE SUPERVISOR’S NAME

DATES EMPLOYED (Month/Day/Year) TOTAL NUMBER OF HOURS WORKED

From: To:
NAME OF EMPLOYER TELEPHONE NUMBER
(INCLUDE AREA CODE)

ADDRESS: NUMBER STREET CITY STATE ZIP CODE

YOUR POSITION TITLE SUPERVISOR’S NAME

DATES EMPLOYED (Month/Day/Year) TOTAL NUMBER OF HOURS WORKED

From: To:
NAME OF EMPLOYER TELEPHONE NUMBER
(INCLUDE AREA CODE)

ADDRESS: NUMBER STREET CITY STATE ZIP CODE

YOUR POSITION TITLE SUPERVISOR’S NAME

DATES EMPLOYED (Month/Day/Year) TOTAL NUMBER OF HOURS WORKED

From: To:
17. List your residence addresses for the past five years. Give the most recent first, using additional sheet if necessary.
NUMBER AND STREET CITY STATE ZIP CODE
FROM TO

ATTENTION – READ THE FOLLOWING PARAGRAPH CAREFULLY BEFORE SIGNING THIS FORM
I declare under penalty of perjury, under the laws of the State of California, that all information contained on this Personal Identification Form and
any accompanying documents is true and correct, with full knowledge that all statements made in this application are subject to investigation and that
any false or dishonest answer to any question may be grounds for denial or subsequent revocation of license.

___________________________________________________________ ________________________________
SIGNATURE DATE

Disclosure Language: Pursuant to Business and Professions Code section 30, providing your social security or individual taxpayer identification number is mandatory
and will be used exclusively for tax enforcement purposes and for compliance with any judgment or order for family support in accordance with section 17520 of the
Family Code. Your social security or individual taxpayer identification number may also be used for verification of licensure or examination status for national
examination where licensure is reciprocal with a requesting state. If you fail to provide your social security or individual taxpayer identification number, you will be
reported to the Franchise Tax Board, which may assess a $100 penalty against you.
Submission of the requested information is mandatory. The Bureau of Security and Investigative Services cannot consider your application for licensure or renewal
unless you provide all of the requested information.
Pursuant to the California Public Records Act (Gov. Code § 6250 et seq.) and the Information Practices Act (Civ. Code § 1798.61), the names and addresses of persons
possessing a license or registration may be disclosed by the Department unless otherwise specifically exempt from disclosure under the law. We make every effort to
protect the personal information you provide us. The information you provide, however, may be disclosed in response to a court or administrative order, a subpoena, or a
search warrant.
Per the Information Practices Act, the Chief of the Bureau of Security and Investigative Services, Department of Consumer Affairs, is responsible for maintaining the
information in this application. You have the right to review the records maintained on you by the Bureau or Department unless the records are exempt from disclosure
by section 1798.40 of the Civil Code. Your completed application becomes the property of the Bureau and will be used by authorized personnel to determine your
eligibility for a license, registration or permit. Information on your application may be transferred to other governmental or law enforcement agencies, as permitted by
law.
For questions about this notice or access to your record, you may contact the Bureau by mail at Bureau of Security and Investigative Services, Attn: Public Records
Liaison, P.O. Box 980550, Sacramento, CA 95798-0550, by phone at (916) 322-4000 or (800) 952-5210, or by e-mail at [email protected]. For questions
about the Department’s Privacy Policy, you may contact the Department of Consumer Affairs at 1625 North Market Boulevard, Sacramento, CA 95834, by phone at
(800) 952-5210 or by e-mail at [email protected].
14 31D-9 (Rev. 01/2022)