SPEGIAL GROUP

SPEGIAL GROUR
Special Group Security Agency, LLC License #C14773801

P.O. 82554, Austin, Texas 78708 Phone: 512-968-6696 eddi@SpecialGroupSecurityAgency.com www.SpecialGroupSecurityAgency.com

Employee Statement & Security Guard Application

In accordance with applicable law, this company is an equal opportunity employer and does not discriminate because of race, religion, color, age, gender, national origin, marital status, disability, genetic information, veteran status, sexual orientation, or any other status protected by law. No question on this application is intended to secure information to be used for such discrimination.

Applicant's Statement of Understanding and Authorization I understand that this application will be given every consideration, but its receipt does not imply that the applicant will be employed. I understand that I may choose to leave any portion of the application incomplete or blank and that the following information is given voluntarily. I understand and authorize the company to obtain a consumer report of my financial and credit record as well as an investigative consumer report whereby information is obtained through personal interviews with neighbors, friends and others to whom I am acquainted with. This investigation includes information about my character, general reputation, personal characteristics and mode of living. I understand that I have the right to make a report. I give my permission to Special Group Security Agency, LLC to contact any of my former employers to release all records of my employment including assessments of my job performance, ability and fitness. I understand that the company may require a motor vehicle record (MVR) report. I understand that Special Group Security Agency, LLC reserves the right to require a medical examination as well as periodic physical and medical examinations and pre-employment as well as post-employment drugandalcohol testing, to the extent permitted by law. I hereby state that if dismissed from Special Group Security Agency, LLC., if I am employed, I understand that such employment is at will and will not result in an employment contract for any specific term unless otherwise specified.

Instructions: Forms must be completed in blue or black ink. Incomplete forms will not be processed.
Application as (Check only One)

Non-Commissioned OfficerCommissioned
Social Security Number
MM/DD/YYYY
(Must be at least 18 years old to apply
City
State
Country
Gender

MaleFemale
First Name
Middle
Last Name
DL/ID #
State
Expires
Restrictions
Race

WhiteBlackAmerican Indian/Alaskan NativeAsian or Pacific IslanderOtherUnknown
Mailing Address: (P.O. Box may be added to ensure delivery
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Email
example@example.com
1. If employed, how soon can you report to work
Full-Time

2. Type of employment:Part-TimeTemporary
3. Desired Salary
MON
TUES
THUR

YESNO
SAT
SUN
5. Are you currently employed?
IF "YES," you must submit an explanation for your desire to make a change of employment.
6. Please provide a description of your security experience, including type of business and your duties.

YESNO
6. Please provide a description of your security experience, including type of business and your duties.
7. Have you ever worked for this company before?
IF "YES," give dates and position held

8. Are you able to meet attendance requirements for this job?
9. Do you have means of transportation to get to and from work?

YESNOYESNO
EMPLOYMENT
Please enter the complete record of your occupation for your previous two employments.
Name of Company
Employment Status: (Full/Part Time)
Hours/Week Worked
Dates of Employment: (From To)

MonthDayYear
Date
Company Address
Supervisor
Business Telephone
Position/Duties
Name of Company
Employment Status: (Full/Part Time)
Hours/Week Worked
Dates of Employment: (From To)

MonthDayYear
Date
Company Address
Supervisor
Business Telephone
Position/Duties
EDUCATION
REFERENCES
GENERAL INFORMATION
Check all uniform items owned

FlashlightTactical BootsHandcuffsSmall LightBlack ShoesHandcuff KeySecurity LightBlack Work ShirtName PlateFirearmBlack Work PantsSecurity BadgeFirearm HolsterLeather Security BeltPepper SprayShotgunNylon Security BeltTaserDark Blue ShirtBullet Proof VestPatrol VehicleBatonOtherOther
Check all Certifications that apply

Level 1 and 2
Time Held
Expiration Date

MonthDayYear
Date
Level 3 Commission

Time Held
Level 3 Commission

PPO (Personal Protection Officer)
Level 3 Commission

P.I. (Private Investigator)
Time Held
Expiration Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Shotgun

CPR
Shotgun

First Aid
Expiration Date

Expiration DateManager's LicenseSupervisor's LicenseSalesperson LicenseTime HeldO.C. SprayBaton
Expiration Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Time Held
Expiration Date

MonthDayYear
Date
BACKGROUND QUESTIONNAIRE
Answer the following questions by checking either "YES" or "NO"
1. Are you a citizen of the United States or a legal resident of the United States in possession of a valid alien registration card? IF "NO," you must submit an explanation.

YESNOYESNOYESNOYESNO
IF "YES," and if you qualify for an exemption, you must submit further documentation. If you DO NOT qualify, you must submit training certificates

3. Are you a retired police officer?

IF "YES, and if you qualify for an exemption, you must submit further documentation. If you DO NOT qualify, you must submit training certificates.

4. Have you ever been convicted in this state or elsewhere of a crime or offense that is a misdemeanor or a felony?

IF "YES,' you must submit with this application a written explanation giving the place, court jurisdiction, nature of the offense, sentence and/or other disposition. You must submit a copy of the accusatory instrument (e.g., indictment, criminal information or complaint) and a Certificate of Disposition. If you possess or have received a Certificate of Relief from Disabilities, Certificateof Good Conduct or Executive Pardon, you must submit a copy with this application.

5. Are there any criminal charges (misdemeanors or felonies) pending against you in any court in this state or elsewhere?

IF "YES," you must submit a copy of the accusatory instrument (e.g., indictment, criminal information or complaint

6. Has any license or permit issued to you or a company in which you are or were a principal in Texas State or elsewhere ever been revoked, suspended or denied? IF "YES," you must submit an explanation.
7. Have you ever been discharged from a correctional or law enforcement agency for incompetence or misconduct as determined by a court of competent jurisdiction, administrative hearing officer, administrative law judge, arbiter, arbitration panel or other duly constituted tribunal, or resigned from such an agency while charged with misconduct or incompetence?

YESNOYESNOYESNO
IF "YES," you must submit an explanation.

8. Have you ever been declared to be incompetent by reason of mental disease or defect, which has not been removed by any court of competent jurisdiction? IF "YES, you must submit an explanation.

9. Have you ever applied in this state or elsewhere for a registration/license as a security guard; watch, guard or patrol agency; private investigator? IF "YES," please provide the UID # or Reg. #.

10. Have you ever served in one of the US Military components, including Reserves, National Guard, or Air National Guard?
IF "YES, Where you discharged in any other means than honorable? Submit an explanation.

YESNOYESNOYESNOYESNO
11. Are you still currently serving as a military member?

IF "YES, you must provide a copy of your DD214 and an explanation of branch and position you served.
SPECIAL GROUP SECURITY AGENCY, LLC
P.O. Box 82554, Austin, Texas 78708 (512)968-6696
APPLICANT AFFIRMATION
I certify that the information I have given in this application is true and completed to the best of my knowledge andunderstand that falsification, omissions, or misrepresentations of this information is grounds for rejection of my employment application and if employed by Special Group Security Agency, LLC or may be terminated immediately. I authorize the character references, previous employers and education institutions listed above to give you any information concerning my previous employment and any pertinent information they may have, personal or otherwise, and all parties from all liability, claims, or for and damage that may result from me. I also release Special Group Security Agency, LLC from any and all liability of whatever kind and nature, which, at any time, could result from obtaining and having an employment, based on such information. I agree to conform to the rules and regulations of the company. Furthermore, I understand that if an offer of employment is extended, it is conditioned upon completing the federal I-9 Form and providing documents establishing identity and work authorization. I understand that my employment can be terminated with or without cause and with or without notice, at any time, at the option of either the company or myself. I understand that only the owner, manager, or representative of the company has the authority to enter into any agreement contrary to the foregoing.

I represent that I am able to meet the attendance requirements as required by the company. I understand that by maintaining a current commission, license and operable mobile phone may be necessary for continued employment.

I have read and fully understood the applicant's affirmation of understanding and authorization (refer to page one of Employee Statement and Security Guard Application
Applicant's Signature

Clear
Date

MonthDayYear
Date
Applicant's Printed Name
NOTICE OF EMPLOYMENT
If employment will commence with the filing of your application, this section MUST be completed by your employer.
Hire Date

MonthDayYear
Date
Assigned to
Termination Date

MonthDayYear
Date
Start Pay Rate
Status

F/TP/TOther
End Pay Rate
SPECIAL GROUP SECURITY AGENCY, LLC

P.O. Box 82554, Austin, Texas 78708 (512)968-6696

DRUG AND/OR ALCOHOL TESTING CONSENT FORM

EMPLOYEE AGREEMENT AND CONSENT TO DRUG AND/OR ALCOHOL TESTING

I hereby agree, upon a request made under the drug/alcohol testing policy of Special Group Security Agency, LLC, to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under company policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to have Special Group Security Agency, LLC and/or its company physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Company and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize the Special Group Security Agency, LLC to disclose any documentation relating to such test to any governmental entity involved in a legal proceeding or investigation connected with the test. I also authorize Special Group Security Agency, LLC to field test my specimen. If evidence is found, further testing may be required.

I understand that only duly authorized Company officers, employees, and agents will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make employment decisions and to respond to inquiries or notices from government entities.

I will hold harmless the Company, its company physician, and any testing laboratory the Company might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as a result of the drug or alcohol test, even if a Company or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless the Company, its company physician, and any testing laboratory the Company might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph

This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.

I UNDERSTAND THAT THE COMPANY WILL REQUIRE A DRUG SCREEN AND/OR ALCOHOL TEST UNDER

THIS POLICY WHENEVER I AM INVOLVED IN AN ON-THE-JOB ACCIDENT OR INJURY UNDER CIRCUMSTANCES THAT SUGGEST POSSIBLE INVOLVEMENT OR INFLUENCE OF DRUGS OR ALCOHOL IN

THE ACCIDENT OR INJURY EVENT, AND I AGREE TO SUBMIT TO ANY SUCH TEST.
Applicant's Signature

Clear
Date Signed

Clear
Applicant's Printed Name
SPECIAL GROUP SECURITY AGENCY, LLC
P.O. Box 82554, Austin, Texas 78708 (512)968-6696
UNIFORM AGREEMENT
First Name
Middle
Last Name
Reg. I.D. #
Each member of staff will be issued with corporate wear based on the Special Group Security Agency, LLC

I promise to return the above listed items that were loaned to me upon termination of my employment or if requested by management. I acknowledge that these loaned items have been issued to me for use during work related functions and not for personal use. It is my responsibility to care for and maintain these items in a responsible manner. I agree that I will be held financially responsible for the payment of the item(s) loaned to me in the event I fail to return them or lost/stolen. I further agree that my employer, Special Group Security Agency, LLC, has the right to deduct the cost of each item from my earnings and/or report me to the Private Security Bureau for the items I fail to return from the above list.
Employee's Signature

Clear
Date

MonthDayYear
Date
SPECIAL GROUP SECURITY AGENCY, LLC
P.O. Box 82554, Austin, Texas 78708 (512) 968-6696
INFORMATION SHEET
AGENT INFORMATION
First Name
Middle
Last Name
Address
Phone
DOB
Nationality
DL/ID #
State
Restrictions
PSB Reg. #
State
Reg. Type
VEHICLE INFORMATION
Make
Model
Year
Color
WEAPON INFORMATION
Primary Type
Model
Caliber
Serial #
Shot Gun Type
Model
Caliber
Serial #
Stun Gun Type
Model
Caliber
Serial #
Type
Model
Caliber
Serial #
Image
Should be Empty:

SPEGIAL GROUR

MON

TUES

SAT

SUN

EMPLOYMENT

EDUCATION

REFERENCES

GENERAL INFORMATION

BACKGROUND QUESTIONNAIRE

SPECIAL GROUP SECURITY AGENCY, LLC

APPLICANT AFFIRMATION

NOTICE OF EMPLOYMENT

SPECIAL GROUP SECURITY AGENCY, LLC

UNIFORM AGREEMENT

SPECIAL GROUP SECURITY AGENCY, LLC

INFORMATION SHEET

AGENT INFORMATION

VEHICLE INFORMATION

WEAPON INFORMATION