Page 2 of 2
*LESO Authorized Signatory:
*
Screener letter is valid one year from this date:
*SIGNATURE
LESO Notes:
(Application Version: Oct 11, 2018
*
PRINTED NAME FIRST & LAST
*
SIGNATURE
*
DATE
SECTION 3:
*TITLE
*EMAIL
*
PRINTED NAME: FIRST & LAS
T
*SIGNATURE
*DATE
SECTION 2:
RESERVED FOR LAW ENFORCEMENT AGENCY USE ONLY
Law Enforcement Agency/Activity - The LESO Program defines this as a Governmental agency/activity whose primary function is the enforcement of
applicable Federal, State and Local laws and whose compensated Law Enforcement officers have the powers of arrest and apprehension.
I certify that my agency meets the definition of a "Law Enforcement Agency/Activity" as described above. I certify that all information
contained in this application is valid and accurate. I understand that I must provide my State Coordinator an appli
cation to update my agency
participant information if the following information changes: 1. Chief Law Enforcement Official (CLEO) changes, 2. Agency physical address
changes or 3. RTD Screener additions/deletions.
I am signing this document as the CLEO of this law enforcement agency.
In my official position or as Acting/Interim, I am authorized to sign documents on behalf of the CLEO for this agency.
If checked, please provide current department policy or Memorandum that provides such signature authority to the
individual holding that official position.
*(Check only one):
*
SECTION 4:
RESERVED FOR LESO USE ONLY
NOTICE FOR DLA DISPOSITION SERVICES PERSONNEL: Regulatory guidance outlining Screener Identification and Authorization must be accomplished in
accordance with DOD 4160.21-M, Volume 3, Enclosure 5, Section 3 (k). In accordance with the aforementioned reference, the LESO Program authorizes the
individuals identified in Section 1 of this form to screen excess property at your facilities as authorized participants in the LESO Program. This authorized
screener letter supersedes all previously issued screener letters for this Law Enforcement Agency/Activity and is valid only on or after the date signed by
authorized LESO signatory. Only two individuals authorized to screen per visit; however, additional personnel may assist receiving material previously screened
and approved for transfer.
*This agency is authorized to screen items via the LESO Program under authorized Agency DODAAC:
RESERVED FOR STATE COORDINATORS OFFICE USE ONLY
As the State Coordinator/ State Point of Contact it has been determined that the agency meets the definition of a "Law Enforcement
Agency/Activity" as described in section 2. I certify that all information contained in this application is valid and accurate.
By signing this application, I certify that my Agency will comply with U.S. Code 2576a for all controlled property, which states; With the
authorization of the relevant local governing body or authority, that my agency has adopted publically available protocols for the
appropriate use of controlled property, the supervision of such use, and the evaluation of the effectiveness of such use, including
auditing and accountability policies; and that it provides annual training to relevant personnel on the maintenance, sustainment, and
appropriate use of controlled property. I certify under penalty of perjury that the foregoing is true and correct. Making a false
statement may result in judicial actions or prosecution under 18 USC § 1001.
Note: Once this screener letter has expired, agency can request
a new screener letter (LESO AUTHORIZATION SCREENER
LETTER, v.MARCH 2018) only through their SC/SPOC.
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
