Form F-5A(LE) "Report of Appointment/Application for Certification Law Enforcement Officer" - North Carolina

What Is Form F-5A(LE)?

This is a legal form that was released by the North Carolina Department of Justice - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the North Carolina Department of Justice;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-5A(LE) by clicking the link below or browse more documents and templates provided by the North Carolina Department of Justice.

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CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Form F-5A (LE)
Rev. 5/16
REPORT OF APPOINTMENT/APPLICATION FOR CERTIFICATION LAW ENFORCEMENT OFFICER
FOR STANDARDS DIVISION ONLY
CERTIFICATION ___________________________________________________
MAILED ____________________________________________________________
TRA
___________________________________________________
FP
____________________________________________________________
INSTRUCTIONS: Please type or print all information clearly. This form shall be completed for EACH individual BEFORE administration of
law enforcement oath irrespective or whether service is to be full-time, part-time, paid, unpaid, regular, reserve, auxiliary, honorary, or special.
This Appointment must be submitted to the Criminal Justice Standards Division for issuance of the appropriate Certification which will be returned to you for
purposes of Oath administration. A copy must be retained in the appointing Agency’s personnel file.
The Social Security Number is used to make positive
identification of application and/or law enforcement personnel. DISCLOSURE IS VOLUNTARY. However, failure to provide this information may result in a delay
in the processing of application materials and may result in inaccurate records being assigned to you.
Employing Agency __________________________________________________
Phone Number: ______________________________________
Address:
____________________________________________________________________________ Zip Code: ___________________________
Check if New Address Agency or ORI Number (If Available. Originating Routing Identifier assigned by NCIC) _____________________________
___________________________
_____________________________________________
Applicant Name:
_____________________________
Last
First
Middle
Applicant's Email:___________________________
List Any Previous Names Used:__________________________________________________
Address:
________________________________________________________________State________
Zip Code: __________________________
Date of Birth: __________________
Driver’s License No: _____________ Social Security No:_______________ ___________________
Status:
Position:
Officer
Chief
Full-Time
Part-Time
Date of Hire:_________________________________________
SECTION FOR NEW APPLICANTS, PROBATIONARY APPLICANTS, AND OUT-OF-STATE TRANSFERS ONLY
This section must be completed indicating that the requirements of the Administrative Code (12 NCAC 9) have been met with necessary forms and
documentation having been placed in applicant’s personnel file prior to submitting this application. Failure to complete any item will result in the return of
this form. *Please attach verification of home/private school registration or credential.
Home School/Private
College/University
Education Requirement:
High School
High School Equivalency
School Information:
__________________________________________________________________________________________________________
(Name of High School/Home School/Private School)
(County, City and State of School)
Education Verified By:
Diploma
Equivalency Credential
Transcript
Other _______________________________________________
Highest Degree Awarded:
High School
2 yr. Degree
4 yr. Degree
Other _______________________________________________
Name of Highest Level Institution Attended: _________________________________________________________________________________________
(Accredited Awarding Institution)
Drug Screening Test:
Positive
Negative
Name of HHS Certified Laboratory
______________________________________________________________________________________
Date Laboratory Reported Test Results ________________________ (Must be within 60 days prior to employment.)
Fingerprint Requirements: Date Submitted to State Bureau of Investigation _________________________________________________________________
Psychological Screening: Date _______Psychologist/Psychiatrist Full Name_______________________________NC License # ______________________
F-1 Medical History Statement (Completed by Applicant) Must be completed within one year prior to employment.
F-2 Medical Examination Report: Date Conducted:____________________Must be conducted within one year prior to employment.
Completed by:
Physician/PA or
Nurse Practitioner
Full name: __________________________________________________ NC License # _________________________________________
F-3 Personal History Statement (Completed, Signed and Dated by Applicant. Must be Notarized)
Qualifications Appraisal Interview MUST be Completed by Agency Head or Representative (Use of Form F-4 is optional)
F-8 Mandated Background Investigation Form (Signed and Dated by Person Conducting Investigation)
F-9A Firearms Qualification Record (Completion of Employing Agency’s In-Service Firearms Training Program) Must Attach Copy of F-9A
Firearms Qualification Date _________________ Also indicate location (agency or facility) ______________________________________
Name of Basic Law Enforcement Training School:____________________________Exam Date: _______________________________________
CRIMINAL JUSTICE EDUCATION AND TRAINING STANDARDS COMMISSION
CRIMINAL JUSTICE STANDARDS DIVISION
Post Office Drawer 149, Raleigh, NC 27602
Telephone: (919) 661-5980
Form F-5A (LE)
Rev. 5/16
REPORT OF APPOINTMENT/APPLICATION FOR CERTIFICATION LAW ENFORCEMENT OFFICER
FOR STANDARDS DIVISION ONLY
CERTIFICATION ___________________________________________________
MAILED ____________________________________________________________
TRA
___________________________________________________
FP
____________________________________________________________
INSTRUCTIONS: Please type or print all information clearly. This form shall be completed for EACH individual BEFORE administration of
law enforcement oath irrespective or whether service is to be full-time, part-time, paid, unpaid, regular, reserve, auxiliary, honorary, or special.
This Appointment must be submitted to the Criminal Justice Standards Division for issuance of the appropriate Certification which will be returned to you for
purposes of Oath administration. A copy must be retained in the appointing Agency’s personnel file.
The Social Security Number is used to make positive
identification of application and/or law enforcement personnel. DISCLOSURE IS VOLUNTARY. However, failure to provide this information may result in a delay
in the processing of application materials and may result in inaccurate records being assigned to you.
Employing Agency __________________________________________________
Phone Number: ______________________________________
Address:
____________________________________________________________________________ Zip Code: ___________________________
Check if New Address Agency or ORI Number (If Available. Originating Routing Identifier assigned by NCIC) _____________________________
___________________________
_____________________________________________
Applicant Name:
_____________________________
Last
First
Middle
Applicant's Email:___________________________
List Any Previous Names Used:__________________________________________________
Address:
________________________________________________________________State________
Zip Code: __________________________
Date of Birth: __________________
Driver’s License No: _____________ Social Security No:_______________ ___________________
Status:
Position:
Officer
Chief
Full-Time
Part-Time
Date of Hire:_________________________________________
SECTION FOR NEW APPLICANTS, PROBATIONARY APPLICANTS, AND OUT-OF-STATE TRANSFERS ONLY
This section must be completed indicating that the requirements of the Administrative Code (12 NCAC 9) have been met with necessary forms and
documentation having been placed in applicant’s personnel file prior to submitting this application. Failure to complete any item will result in the return of
this form. *Please attach verification of home/private school registration or credential.
Home School/Private
College/University
Education Requirement:
High School
High School Equivalency
School Information:
__________________________________________________________________________________________________________
(Name of High School/Home School/Private School)
(County, City and State of School)
Education Verified By:
Diploma
Equivalency Credential
Transcript
Other _______________________________________________
Highest Degree Awarded:
High School
2 yr. Degree
4 yr. Degree
Other _______________________________________________
Name of Highest Level Institution Attended: _________________________________________________________________________________________
(Accredited Awarding Institution)
Drug Screening Test:
Positive
Negative
Name of HHS Certified Laboratory
______________________________________________________________________________________
Date Laboratory Reported Test Results ________________________ (Must be within 60 days prior to employment.)
Fingerprint Requirements: Date Submitted to State Bureau of Investigation _________________________________________________________________
Psychological Screening: Date _______Psychologist/Psychiatrist Full Name_______________________________NC License # ______________________
F-1 Medical History Statement (Completed by Applicant) Must be completed within one year prior to employment.
F-2 Medical Examination Report: Date Conducted:____________________Must be conducted within one year prior to employment.
Completed by:
Physician/PA or
Nurse Practitioner
Full name: __________________________________________________ NC License # _________________________________________
F-3 Personal History Statement (Completed, Signed and Dated by Applicant. Must be Notarized)
Qualifications Appraisal Interview MUST be Completed by Agency Head or Representative (Use of Form F-4 is optional)
F-8 Mandated Background Investigation Form (Signed and Dated by Person Conducting Investigation)
F-9A Firearms Qualification Record (Completion of Employing Agency’s In-Service Firearms Training Program) Must Attach Copy of F-9A
Firearms Qualification Date _________________ Also indicate location (agency or facility) ______________________________________
Name of Basic Law Enforcement Training School:____________________________Exam Date: _______________________________________
SECTION FOR N.C. TRANSFERS ONLY
If Applicant is a lateral transfer (holds GFA or GNA Certification), indicate the following North Carolina Administrative Code (12 NCAC 9C .0306)
requirements have been met and appropriate documentation has been placed in the applicant’s personnel file prior to employment.
Date of Hire: ____________________
Fingerprint Requirements: Date Submitted to State Bureau of Investigation:__________________________
F-1 Medical History Statement (Completed by Applicant): Must be completed within one year prior to transfer.
F-2 Medical Examination Report: Must be conducted within one year prior to transfer. Date Conducted: ______________
__
____
__________________
Completed by:
Physician/PA or
Nurse Practioner
___
____
_____
NC License # _____________________________________
____
Full name: ______________________________________________________
Drug Screen
:
Positive
Negative
Date Laboratory Reported Test Results: _____________________________
(Must be within 60 days prior to employment.)
Name of HHS Certified Laboratory: _________________________________
Firearms Qualification
: Indicate one of the following and attach copy of Firearms Qualification Record (Form F-9A).
Applicant successfully completed this agency’s In-Service Firearms Qualification. Qualification Date: _______________________________________
Applicant successfully completed In-Service Firearms Qualification at the previous agency and the on-duty weapon and the off-duty weapon(s) shall remain
the same as the one used to qualify within the preceding 12 month period.
Qualification Date: _________Location (agency or facility)_____________________NOTE: Attach copy of Firearms Qualification Record (Form F-9A)
Law Enforcement Experience
: Previous L.E. Agency _______________________________
Date of Separation (if applicable)__________________
Does applicant intend to hold dual appointments?
Yes
No
ALL APPLICANTS & TRANSFERS MUST READ AND COMPLETE THIS CRIMINAL RECORD SECTION IN THEIR OWN HANDRWITING.
Each applicant must list any and all criminal charges regardless of the date of offense and the disposition (to include dismissals, not guilty, nol pros, PJC, or any
other disposition where you entered a plea of guilty). Do not include minor traffic offenses (N.C.G.S. Chapter 20), but specifically include DWI, DUI, driving
while under the influence of drugs, driving while license permanently revoked, speeding to elude arrest, or duty to stop in event of accident. If you list a charge(s),
please attach certified and true copies of warrant(s) and judgment(s) for each offense, even if documentation and charges have previously been reported to this
agency. Attach additional sheets if needed.
No Criminal Charges
No Criminal Charges other than Minor Traffic Offenses
Applicant Initials ___________
Applicant Initials _________
1. Offense Charged: _____
________________________________________
Charging Law Enforcement Agency: _________________________
Date of Offense: ______________________ Disposition of Case and Date: __
____________________________________________________
2. Offense Charged: _____________________________________________ Charging Law Enforcement Agency: _________________________
Date of Offense: ______________________ Disposition of Case and Date: ______________________________________________________
3. Offense Charged: _____________________________________________ Charging Law Enforcement Agency: _________________________
Date of Offense: ______________________ Disposition of Case and Date: ______________________________________________________
As the applicant for certification, I attest that I am aware of the minimum standards for employment, that I meet or exceed each of those requirements, that the
information provided above and all other information submitted by me, both oral and written throughout the employment and certification process, is thorough,
complete, and accurate to the best of my knowledge. I further understand and agree that any omission, falsification or misrepresentation of any factor or
portion of such information can be the sole basis for termination of my employment and/or denial, suspension or revocation of my certification at any time,
now or later. I further understand that I have a continuing duty to notify the Commission of all criminal offenses which I am arrested for or charged
with, plead no contest to, plead guilty to or am found guilty of. If applicable, I specifically acknowledge that my continued employment and certification are
contingent on the results of the fingerprint records check and other criminal history records being consistent with the information provided in my Personal History
Statement and as reflected in this application.
______________________________________________________________________________________________________________________
Signature of Applicant/Candidate
Date
I, as an official representative of the appointing agency, do submit to the Commission the above-named appointee as a candidate for certification. The candidate
meets or exceeds each of the minimum standards for employment and this agency has properly conducted the required employment procedures as established by
the Commission and incorporated into 12 NCAC 9. All documents necessary to insure compliance with the rules of the Code are being retained in the personnel
files of this agency and may be inspected at any reasonable time by representatives of the Commission. I acknowledge that any omission, falsification or
misrepresentation of information or procedures, by either the candidate or this agency throughout the employment and/or certification process, may result
in certification being denied, suspended or revoked by the Commission at any time, now or later.
________________________________________________________________________________________________________________________
Signature of Executive Officer or Registered Authorized Representative
Title
Date
Form F-5A (LE), Rev. 5/16
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