Fillable PRIVATE PATROL OPERATOR LICENSEE (California)

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PRIVATE PATROL OPERATOR LICENSEE (California)

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STATE OF CALIFORNIA – BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY GAVIN NEWSOM, GOVERNOR
BUREAU OF SECURITY AND INVESTIGATIVE SERVICES
P.O. Box 989002, West Sacramento, CA 95798-9002
P (916) 322-4000 (800) 952-5210 │F (916) 575-7290 │www.bsis.ca.gov
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PRIVATE PATROL OPERATOR LICENSEE
REQUEST COMPANY NAME CHANGE FORM
REQUEST ADDITIONAL FICTITIOUS BUSINESS NAME FORM
IMPORTANT: A $75.00 processing fee must be submitted with the form. Read ALL instructions for completing
this form. An incomplete or incorrectly completed form will delay processing.
COMPLETE ELECTRONICALLY ON COMPUTER OR PRINT CLEARLY IF HANDWRITTEN
REQUESTOR INFORMATION
(See Item 2 of Instructions)
Current Company Name on License
PPO License Number
Requestor (See Instructions) First Name Middle Initial Last Name
Requestor’s Title
Email Address (Optional)
Phone Number
Check this box if you want to change your company’s address on file with the Bureau. Read Item 4
of Instructions if providing change of address information.
Address of Record Street Address City State Zip Code
Residence Address Street Address City State Zip Code
Check Only One Box
Check this box if requesting to change name on license.
Check this box if requesting an additional fictitious business name (FBN) to associate with license.
LIST OF PREFERENCES FOR NEW NAME/ADDITIONAL FBN
Only one change in name or FBN approval per form. Because a requested name may not be permitted
(e.g., similar to another licensee’s name or governmental agency), please provide three possible names
in order of your preference for consideration/approval.
NOTE: Read items 5 through 7 of Instructions carefully.
First Preference Name
Second Preference Name
Third Preference Name
January 2019 Page 1 of 3
Submission of the requested information is mandatory. The Bureau of Security and Investigative Services (BSIS)
of the Department of Consumer Affairs (Department) cannot process your Name Change Form unless all
requested information is provided.
Per the Information Practices Act, the Chief of the BSIS is responsible for maintaining the information in this form.
You have the right to review the records maintained on you by the BSIS or Department unless the records are
exempt from disclosure by section 1798.40 of the Civil Code. Your completed form becomes the property of the
BSIS 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.
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, certificate, permit or registration
may be disclosed by the BSIS unless otherwise specifically exempt from disclosure under the law. The BSIS
makes every effort to protect the exempt 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.
For questions about this notice or access to your record, contact BSIS by mail at: Bureau of Security and
Investigative Services, Attn: Custodian of Record, P.O. Box 980550, Sacramento, CA 95798-0550; by phone at
(800) 952-5210; or by e-mail at BSIS.PRArequests@dca.ca.gov. 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 dca@dca.ca.gov.
REQUESTOR’S CERTIFICATION
I declare under penalty of perjury, under the laws of the State of California, that:
• I personally completed this form;
• To the best of my knowledge all statements on this form are true and accurate;
• I did not change my company name for purposes of fraud and/or deception; and
• With full knowledge that all statements herein are subject to investigation and that any false,
dishonest, or incomplete answer to any question on this form may be grounds for disciplinary action
on my private investigator license and any other license(s) I hold, or may subject me to criminal
prosecution.
Requestor’s Signature (No Electronic Signature/Only Handwritten Signature Accepted)
Date
Read ALL instructions for completing this form on page 3. An incomplete
or incorrectly completed form will delay the processing of
your requested change(s).
January 2019 Page 2 of 3
MANDATORY DISCLOSURE LANGUAGE
INSTRUCTIONS FOR COMPLETING THIS FORM
1. Fee Payment: Make your personal check, money order, or cashier’s check payable to the Bureau of
Security & Investigative Services or BSIS. SUBMITTING CASH BY MAIL IS NOT PERMITTED.
A form received without full payment of the $75.00 fee will not be processed and will be returned to
requestor.
2. Requestor: This form is to be used only by a current Private Patrol Operator (PPO) licensee. Only a
principal reflected in the Bureau’s records as associated with the license is authorized to request a
name change or FBN on the license.
a. Sole Ownership: Only the owner associated with the license
b. Partnership: Only a partner associated with the license
c. Corporation: Only an officer associated with the license
3. Email Address: While optional, providing an email address may expedite the Bureau’s
communication with you if additional information is required to process this form.
4. Address Information: A PPO licensee must have the complete address of its principal place of
business on file with the Bureau as the address of record (AOR). The AOR is public information. If
the principal place of business is a personal residence, the address of record may be a post office
box or the address of a mail box service. NOTE: If you are using a post office box or address of a
mail box service as your business’ address of record, you also must provide your residence address
to the Bureau (Section 606 of Title 16, Division 7 of the California Code of Regulations).
5. Use of Business Name: By law, you cannot operate your licensed business under a name that has
not been approved by the Bureau.
6. Fictitious Business Name: The name(s) you are requesting may require a fictitious business
name (FBN) filing. Below is general information on when you need to file a FBN Statement
with your County Clerk’s Office. Refer to Business and Professions Code Section 17900 et. al.
for specific information on FBNs.
a. Sole Ownership: Name does not include last name of owner or suggests additional owners (e.g.,
using “Associates” or “and Company.”
b. Partnership: Name does not include last name of each general partner or suggests additional
owners.
c. Corporation: Name differs from name filed with the California Secretary of State’s Office.
7. Name Approval Process: If requested name is an FBN, DO NOT FILE an FBN Statement with your
County Clerk’s Office until AFTER receipt of the Bureau’s approval of the name.
Step One: Obtain the Bureau’s approval for the FBN.
Step Two: After the Bureau’s approval, file the approved FBN with your County Clerk’s Office and
provide the Bureau with a copy of the FBN Statement with County Clerk’s endorsement of the filing.
8. Change in Business Structure: If you are seeking a name change because the business structure
associated with your license has changed (example: sole owner to corporation), an unauthorized
assignment of the license likely has occurred, and continued use of the current license would
constitute unlicensed activity. Contact the Bureau immediately at
privatesecurityservices@dca.ca.gov if you have changed the business structure associated with your
license to determine if an application for assignment of the license or an application for a new license
is needed.
9. Change in Business Ownership: If you are seeking a name change because the ownership of the
business has changed, the new owner cannot use the current license number and an application for a
new license is required. Continued use of the current license by a new owner is unlicensed activity.
Contact the Bureau immediately about starting the process for a new license at
privatesecurityservices@dca.ca.gov if the licensed business has changed ownership.
January 2019 Page 3 of 3
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PRIVATE PATROL OPERATOR LICENSEE (California)

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Completed 9 January 2022

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