Form F-4 "Personnel Change-In-status Report" - Arkansas

What Is Form F-4?

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

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the Arkansas Department of Public Safety;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form F-4 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Public Safety.

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Download Form F-4 "Personnel Change-In-status Report" - Arkansas

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Form F-4
COMMISSION ON LAW ENFORCEMENT STANDARDS AND TRAINING
PERSONNEL CHANGE-IN-STATUS REPORT
This form should be completed and returned to the Commission on Law Enforcement Standards and Training within ten (10) days of
action.
Reporting Agency
Date:
Agency Contact Number
Officer’s Name
(Rank/First/MI/Last Name/Badge #)
CLEST ID
SSN
DOB
Date Employed
(Month/Day/Year)
Status:
Full Time
Auxiliary Law Enforcement Officer
Part-Time
Specialized Police Personnel
Other – Specify
Part-Time II
Retired
In good standing?
Yes
No
CHECK ONE
TYPE OF ACTION
DATE OF ACTION
(Month/Day/Year)
Resigned – Reason
(Do you recommend Decertification?
Yes
No) (*If yes review requirements on next page.)
Dismissed – Reason
(Do you recommend Decertification?
Yes
No) (*If yes review requirements on next page.)
If separated for a reason listed under Arkansas State Statute 12-9-602(b)(2),
please check the correct Paragraph and attach a statement of facts.
A
B
C
D
Other Reason – (Specify)
Change in Rank – From:
To:
Name Change:
From:
To:
I hereby attest to the best of my knowledge the information submitted on this form is true and correct.
Signature:
Title:
Printed Name:
Email:
SWORN AND SUBSCRIBED BEFORE ME
NOTARY PUBLIC, THIS
day of ______________________________, 20________
My Commission expires
Revised 07-16
Form F-4
COMMISSION ON LAW ENFORCEMENT STANDARDS AND TRAINING
PERSONNEL CHANGE-IN-STATUS REPORT
This form should be completed and returned to the Commission on Law Enforcement Standards and Training within ten (10) days of
action.
Reporting Agency
Date:
Agency Contact Number
Officer’s Name
(Rank/First/MI/Last Name/Badge #)
CLEST ID
SSN
DOB
Date Employed
(Month/Day/Year)
Status:
Full Time
Auxiliary Law Enforcement Officer
Part-Time
Specialized Police Personnel
Other – Specify
Part-Time II
Retired
In good standing?
Yes
No
CHECK ONE
TYPE OF ACTION
DATE OF ACTION
(Month/Day/Year)
Resigned – Reason
(Do you recommend Decertification?
Yes
No) (*If yes review requirements on next page.)
Dismissed – Reason
(Do you recommend Decertification?
Yes
No) (*If yes review requirements on next page.)
If separated for a reason listed under Arkansas State Statute 12-9-602(b)(2),
please check the correct Paragraph and attach a statement of facts.
A
B
C
D
Other Reason – (Specify)
Change in Rank – From:
To:
Name Change:
From:
To:
I hereby attest to the best of my knowledge the information submitted on this form is true and correct.
Signature:
Title:
Printed Name:
Email:
SWORN AND SUBSCRIBED BEFORE ME
NOTARY PUBLIC, THIS
day of ______________________________, 20________
My Commission expires
Revised 07-16
(2) IN CASE OF A SEPARATION FROM EMPLOYMENT OR APPOINTMENT FOR ONE OF THE
FOLLOWING REASONS, THE NOTICE SHALL SO STATE:
(A) THE LAW ENFORCEMENT OFFICER WAS SEPARATED FOR HIS OR HER FAILURE
TO MEET THE MINIMUM REQUIREMENTS FOR EMPLOYMENT OR APPOINTMENT
AS A LAW ENFORCEMENT OFFICER;
(B) THE LAW ENFORCEMENT OFFICER WAS DISMISSED FOR A VIOLATION OF
STATE OR FEDERAL LAW;
(C) THE LAW ENFORCEMENT OFFICER WAS DISMISSED FOR A VIOLATION OF THE
REGULATIONS OF THE LAW ENFORCEMENT AGENCY; OR
(D) THE LAW ENFORCEMENT OFFICER RESIGNED WHILE HE OR SHE WAS THE
SUBMITTED OF PENDING INTERNAL INVESTIGATION.
*Decertification requests must be accompanied by sufficient documentation to support the
allegations against the officer. Failure to submit documentation may result in delayed or no
action on the request for decertification. In addition, the officer’s current home address and
telephone number must be submitted in order for CLEST to contact the officer in
accordance with CLEST regulations.
Revised 07-16
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