Change of Status Form - Georgia

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GEORGIA PEACE OFFICER STANDARDS AND TRAINING COUNCIL
CHANGE OF STATUS FORM
SECTION A MUST BE COMPLETED
Last Name
First Name
MI
SSN
DOB
Race
Sex
Female
White (not Hispanic or Latino)
Agency Name
Agency ID #
SECTION B MUST BE COMPLETED
Type of Change: check one box and complete the corresponding sections below.
New Hire
Promotion
Rank Change
(COMPLETE SECTIONS C AND F)
Separation (COMPLETE SECTIONS D AND F)
Name Change
Education Change
(COMPLETE SECTIONS E AND F)
Deceased
(COMPLETE SECTIONS C AND F)
SECTION C
Date:
Rank/Position
SECTION D
Date:
Type of Separation:
Voluntary Resignation
Career Retirement
Layoff
Resignation in Lieu of Dismissal
Dismissal
If resignation in lieu of dismissal,
Resignation While Under Investigation
dismissal, suspension, or demotion is
Medical Disability Retirement
Medical Disability
checked, reason for disciplinary action
Suspension: Number of Days Suspended:
must be indicated below.
Demotion
From:
To:
(indicate ranks above)
Reason for Disciplinary Action:
Officer’s Last Known Address:
SECTION E
Legal Name Change To:
Note: Legal document of change must be attached.
Education Change To:
Note: Copy of degree or transcript showing degree conferred must be attached.
SECTION F
Authorizing Signature
Date
Telephone Number
Email: _______________________
POST Form C-11 - 12/2007
Print Form
GEORGIA PEACE OFFICER STANDARDS AND TRAINING COUNCIL
CHANGE OF STATUS FORM
SECTION A MUST BE COMPLETED
Last Name
First Name
MI
SSN
DOB
Race
Sex
Female
White (not Hispanic or Latino)
Agency Name
Agency ID #
SECTION B MUST BE COMPLETED
Type of Change: check one box and complete the corresponding sections below.
New Hire
Promotion
Rank Change
(COMPLETE SECTIONS C AND F)
Separation (COMPLETE SECTIONS D AND F)
Name Change
Education Change
(COMPLETE SECTIONS E AND F)
Deceased
(COMPLETE SECTIONS C AND F)
SECTION C
Date:
Rank/Position
SECTION D
Date:
Type of Separation:
Voluntary Resignation
Career Retirement
Layoff
Resignation in Lieu of Dismissal
Dismissal
If resignation in lieu of dismissal,
Resignation While Under Investigation
dismissal, suspension, or demotion is
Medical Disability Retirement
Medical Disability
checked, reason for disciplinary action
Suspension: Number of Days Suspended:
must be indicated below.
Demotion
From:
To:
(indicate ranks above)
Reason for Disciplinary Action:
Officer’s Last Known Address:
SECTION E
Legal Name Change To:
Note: Legal document of change must be attached.
Education Change To:
Note: Copy of degree or transcript showing degree conferred must be attached.
SECTION F
Authorizing Signature
Date
Telephone Number
Email: _______________________
POST Form C-11 - 12/2007
INSTRUCTIONS FOR COMPLETING POST CHANGE OF STATUS (C-11) FORMS
1. Complete the following fields in SECTION A: Agency Name, Agency ID, Social Security Number,
Last Name, First Name, MI, Date of Birth, Race, Sex, and Educ.
2. Indicate the type of change in SECTION B.
3. The remaining sections to be completed depend upon the type of change. SECTION B specifies
the appropriate sections to be completed for each type of change. Complete the remaining
indicated sections after completing SECTION A and SECTION B.
4. The CEO or another individual authorized by the CEO must sign and date each C-11 and provide
a telephone number where that individual can be reached.
Information about completing C-11 forms:
►This form is designed for use in Microsoft Word. Navigation of the form requires use of the TAB
key or mouse pointer to complete fields. To complete a check box, press the space bar or click the left
mouse button on the box.
►The use of this form requires medium security for macros in Microsoft Word. When opening the
form, the screen should display a message asking whether the user wishes to enable or disable macros.
The user must click on “Enable Macros” in order for the form to work properly. Any questions
concerning setup of Microsoft Word functions should be directed to agency computer system
personnel. POST does not provide Microsoft Word software, nor does it provide installation or
modification services for Microsoft Word software.
►Microsoft Word incorporates security features for macros in its software due to the possibility of
macros containing viruses. Macros provided in this file have been screened using industry-standard
software with updated virus definitions. However, POST cannot guarantee the safety of macros
contained in files agencies receive from other sources. Prior to enabling macros in a file, the user
should be absolutely sure of the integrity of the file and the absence of software viruses.
►C-11 forms are used to report personnel changes on certified or registered individuals and on
candidates who have an application on file for certification at POST. Applicants who have no
previous law enforcement experience and are uncertified are reported to POST via an Application for
Peace Officer Certification.
SUBMIT C-11 forms to:
Georgia POST Council
C-11 Processing
P.O. Box 349
Clarkdale, Georgia 30111
FAX (770) 732-5952
C-11 forms may be mailed or faxed. Please do not mail originals when faxing. Electronic submission
of C-11 forms is not available at this time.

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