PERSONAL REFERENCE QUESTIONNAIRE

TO APPLICANT: Print your name, the date and phone number below and have each of your character

references complete the personal reference questionnaire. This form will be uploaded during your application

process. Keep the original with your application confirmation page as it may be requested for review by your assigned

investigator.

Name: ______________________________ Date: __________ License Type: ______________ Ph: ________________

***YOUR APPLICATION WILL NOT BE PRESENTED TO THE BOARD UNTIL ALL REFERENCES HAVE BEEN RECEIVED***

REFERENCE: This questionnaire is to be completed by the reference only, signature notarized and returned to

Applicant.

How long have you known the applicant? __________________________________________________________________

Do you know him/her personally or professionally? __________________________________________________________

Have you ever known the applicant to have alcohol or drug problems? ___________________________________________

What kind of person do you think he/she is and how would you summarize his/her moral character? ___________________

_____________________________________________________________________________________________________________________________

Have you ever observed or had knowledge of the applicant doing anything you felt was illegal or questionable?

____________________________________________________________________________________________________

Is there anything else about the applicant that has not been asked that you feel we need to know about him/her before we

grant the applicant a license? _____________________________________________________________________________

____________________________________________________________________________________________________

Would you recommend the applicant for the license that he/she has requested? _____________________________________

Reference Name: _______________________________________ Date: _________________

Signature: _____________________________________________

Address: City/State/Zip___________________________________________________________

Telephone: __________________________________

THE ABOVE WAS SWORN AND SUBSCRIBED BEFORE ME THIS

The __________Day of_______________________, 20________

__________________________________________________________ (SEAL)

Notary Public

My Commission Expires: _____________________________________

NORTH CAROLINA

PRIVATE PROTECTIVE SERVICES BOARD

3101 Industrial Drive • Suite 104

Raleigh, North Carolina 27609

Phone: (919) 788-5320 • Fax: (919) 715-0379

Web Page: www.ncdps.gov/PPS