Get Bouncer Training

CITY OF PHILADELPHIA OFFICE OF THE MANAGING DIRECTOR 1401 John F. Kennedy Blvd. Suite 1430 Municipal Services Building Philadelphia PA 19102 215-686-3480 Bouncer Training Instructor/Facilities Application Name of Organization Commercial Activity License Number Mailing Street Address PO Box Number City State Zip Code Training Site Street Address If different from mailing address Telephone Number area code number Facsimile Number area code number Name of Applicant Title Name of Owner Contact Number If sole proprietor complete the following Name Date of Birth Social Security Number Last Name First Name MI Years of Experience Has the Instructor had any instances of improper use of force/violence In the past 3 years if yes please describe Description of Experience Provide Additional Instructors on a Separate Sheet On a Separate Sheet provide a full detailed description of the 16 hour training courses given the required certification curriculum. Also provide a description of the 8 hour re-fresher course. Applicant Affirmation This application must be signed and sworn by the applicant before a Notary Public I hearby affirm under penalties of perjury that the information provided in this application is true to the best of my knowledge and belief* I understand that any material misstatement may be deemed sufficient reason to deny approval or may result in the suspension or revocation of the training facility and instructor s approval if issued* I hereby acknowledge that I have thoroughly read and understand the regulations and curriculum requirements. I further understand that all instructors are required to become certified bouncers annually by July 1 as stated in the regulations. Applicant Notary Stamp Print Name Applicant Signature Sworn and subscribed before me on this Notary Signature Date day of. Applicant Affirmation This application must be signed and sworn by the applicant before a Notary Public I hearby affirm under penalties of perjury that the information provided in this application is true to the best of my knowledge and belief* I understand that any material misstatement may be deemed sufficient reason to deny approval or may result in the suspension or revocation of the training facility and instructor s approval if issued* I hereby acknowledge that I have thoroughly read and understand the regulations and curriculum requirements. I further understand that all instructors are required to become certified bouncers annually by July 1 as stated in the regulations. I further understand that all instructors are required to become certified bouncers annually by July 1 as stated in the regulations. Applicant Notary Stamp Print Name Applicant Signature Sworn and subscribed before me on this Notary Signature Date day of. Applicant Affirmation This application must be signed and sworn by the applicant before a Notary Public I hearby affirm under penalties of perjury that the information provided in this application is true to the best of my knowledge and belief* I understand that any material misstatement may be deemed sufficient reason to deny approval or may result in the suspension or revocation of the training facility and instructor s approval if issued* I hereby acknowledge that I have thoroughly read and understand the regulations and curriculum requirements. I further understand that all instructors are required to become certified bouncers annually by July 1 as stated in the regulations. Applicant Notary Stamp Print Name Applicant Signature Sworn and subscribed before me on this Notary Signature Date day of.