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026-0173E (2015/04) © Queen's Printer for Ontario, 2015 Disponible en français Ministry of Community Safety and Correctional Services Notice of a Change in Officers, Directors or Partners of Agencies that Provide Security Guard and/or Private Investigator Services This space reserved for office use only Part 1 - Instructions Use this form to notify the Registrar of any change in the agency's Officers, Directors and/or Partners per section 8 (2) of the Private Security and Investigative Services Act, 2005 (PSISA). • Print clearly and complete all sections of this application using black or dark blue ink only. Do not use correction fluid/white-out. • Complete this Notice of Change form for each new Officer, Director and/or Partner. Please send your completed application package to: ServiceOntario Occupational Licensing Services Office PO Box 4500 Kingston ON K7L 0E1 For assistance, contact a Customer Service Representative at 416 212-1650 or toll-free at 1 866 767-7454 or 416-212-6319 / 1 800 268-7095 (for TTY/Teletypewriter users). You may also visit our website at http://www.mcscs.jus.gov.on.ca/english/PSIS/AboutPSIS/PSIS_about.html. Supporting Documentation • For Corporations, please send a copy of the company resolution and Corporation Profile Report (provided by Ministry of Government Services). If your business is incorporated federally or in another province, please submit proof of change from the appropriate jurisdiction. • For Partnerships, please submit the Amended Master Business Licence and a copy of the partnership agreement. • After receipt of this notification, the Registrar may consent to your agency continuing to act or offer services under the licence. The Private Security and Investigative Services Branch (PSISB) will contact your agency to secure additional information to conduct background checks on any new Director(s), Officer(s) and/or Partner(s). Part 2 - Agency Information Ontario Agency Licence No. Business Name Business Phone No. ext. Email Address Contact Information Last Name First Name Middle Name(s) Business Phone No. ext. Part 3 - Change of Officer, Director or Partner Information Please specify whether you have added a new Officer, Director and/or Partner OR removed same. New Remove Ontario Agency Licence No. (if applicable) Last Name First Name Middle Name(s) Other Name(s) (Maiden name, former name, etc. – please specify) Date of Birth (yyyy/mm/dd) Position Note: Any person who knowingly provides false information in any application or form under the Private Security and Investigative Services Act, 2005 is guilty of an offence and may be refused a licence. Date of Signature (yyyy/mm/dd) Signature of Authorized Agency Representative ►
