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O. Box 182001 Columbus OH 43218-2001 PHONE 614 466-4130 FAX 614 466-0342 www. pisgs. ohio. gov PISGS EMPLOYEE TERMINATION REPORT Fill out all sections of the report. OHIO DEPARTMENT OF PUBLIC SAFETY PRIVATE INVESTIGATOR SECURITY GUARD SERVICES 1970 West Broad Street P. Incomplete reports and reports that are filled out improperly will not be returned for correction* Mail this report with wallet cards to the address listed above. LICENSEE INFORMATION COMPANY NAME LICENSEE FILE TRADE NAME ADDRESS PHYSICAL ADDRESS CITY DAYTIME PHONE TERMINATED EMPLOYEE SSN STATE FAX TERMINATED EMPLOYEE NAME As It Appears on I. D. Card ZIP E-MAIL ADDRESS HIRE DATE Per Employer s Payroll Records MM/DD/YY TERMINATION DATE I. D. CARD STATUS I. D. CARD PENDING APPLICATION RETURNED DID NOT NO CARD TO ODPS RETURN RECEIVED I affirm that the information provided is complete and accurate. Incomplete reports and reports that are filled out improperly will not be returned for correction* Mail this report with wallet cards to the address listed above. LICENSEE INFORMATION COMPANY NAME LICENSEE FILE TRADE NAME ADDRESS PHYSICAL ADDRESS CITY DAYTIME PHONE TERMINATED EMPLOYEE SSN STATE FAX TERMINATED EMPLOYEE NAME As It Appears on I. LICENSEE INFORMATION COMPANY NAME LICENSEE FILE TRADE NAME ADDRESS PHYSICAL ADDRESS CITY DAYTIME PHONE TERMINATED EMPLOYEE SSN STATE FAX TERMINATED EMPLOYEE NAME As It Appears on I. D. Card ZIP E-MAIL ADDRESS HIRE DATE Per Employer s Payroll Records MM/DD/YY TERMINATION DATE I. D. D. Card ZIP E-MAIL ADDRESS HIRE DATE Per Employer s Payroll Records MM/DD/YY TERMINATION DATE I. D. CARD STATUS I. D. CARD PENDING APPLICATION RETURNED DID NOT NO CARD TO ODPS RETURN RECEIVED I affirm that the information provided is complete and accurate. Incomplete reports and reports that are filled out improperly will not be returned for correction* Mail this report with wallet cards to the address listed above. LICENSEE INFORMATION COMPANY NAME LICENSEE FILE TRADE NAME ADDRESS PHYSICAL ADDRESS CITY DAYTIME PHONE TERMINATED EMPLOYEE SSN STATE FAX TERMINATED EMPLOYEE NAME As It Appears on I. D. Card ZIP E-MAIL ADDRESS HIRE DATE Per Employer s Payroll Records MM/DD/YY TERMINATION DATE I. D. LICENSEE INFORMATION COMPANY NAME LICENSEE FILE TRADE NAME ADDRESS PHYSICAL ADDRESS CITY DAYTIME PHONE TERMINATED EMPLOYEE SSN STATE FAX TERMINATED EMPLOYEE NAME As It Appears on I. D. Card ZIP E-MAIL ADDRESS HIRE DATE Per Employer s Payroll Records MM/DD/YY TERMINATION DATE I. D. CARD STATUS I. D. CARD PENDING APPLICATION RETURNED DID NOT NO CARD TO ODPS RETURN RECEIVED I affirm that the information provided is complete and accurate.