Fillable APPLICATION FOR BASIC LAW ENFORCEMENT SCHOOL TENNESSEE LAW (Maury County Government)

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APPLICATION FOR BASIC LAW ENFORCEMENT SCHOOL TENNESSEE LAW (Maury County Government)

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IN 1542 / RDA 1493 (Rev. 5/2015)
APPLICATION FOR BASIC LAW ENFORCEMENT SCHOOL
TENNESSEE LAW ENFORCEMENT TRAINING ACADEMY
3025 LEBANON PIKE
NASHVILLE, TN 37214-2217
Name Social Security No.
(Last) (FULL First) (FULL Middle) (FULL number required)
Mailing Address City
State Zip Code County Driver’s License No.
Phone
(include area code)
Age Date of Birth Male Female
(mm/dd/yyyy)
Height Weight Race
Notify in Emergency Phone
Name Relationship
BASIC POLICE SCHOOL
Date of school requested
If above school is filled, give alternative school and date
EMPLOYMENT
HISTORY
Name
of
present
employer
Status of Employment Full-time Commissioned Part-time Commissioned
Other
Date of full-time commission by present employer
Job classification (title/rank)/duties
Have you
had
prior
law
enforcement
experience? Yes No
If
you
have
prior
law
enforcement experience, give name
of
law enforcement agency
and date(s).
Have
you
been
a
certified officer
in Tennessee? Yes No
Date certified
Have you been a certified officer in a state other than Tennessee?
Yes No
If YES, give State and date certified
Student Email
IN 1542 / RDA 1493 (Rev. 5/2015)
Application
for Basic Law
Enforcement
School
(continued)
Page
2
EDUCATIONAL BACKGROUND
Date of high school diploma
OR
Date of state recognized GED certificate
List schools attended after high school (College, Trade, etc.). Give dates and degree(s):
MILITARY SERVICE
Yes No
Type of Discharge
OTHER INFORMATION
Are you
physically
able to perform vigorous physical activities?
Yes No
IF YOU HAVE EVER BEEN ARRESTED AND/OR CONVICTED OF A CRIME FOR WHICH YOU HAVE A VALID
EXPUNGEMENT ORDER FROM THE COURT, AND YOUR RECORD FOR THAT ARREST HAS BEEN EXPUNGED,
YOU DO NOT HAVE TO REFLECT THAT ARREST AND/OR CRIME ON THIS APPLICATION. T.C.A. §40-
32.101(G),15(C).
FAILURE TO REPORT AN ARREST OR CRIME THAT HAS NOT BEEN PROPERLY EXPUNGED WILL BE
CONSIDERED AS A FALSE STATEMENT AND WILL BE GROUNDS FOR NON-ACCEPTANCE OR DISMISSAL
FROM THIS ACADEMY. YOU MUST HAVE A VALID EXPUNGEMENT ORDER FROM THE COURT.
Have you ever been
arrested
for any criminal violation?
Yes No
Signature of Applicant Date
Have you ever been
convicted of
any criminal violation other than a traffic violation?
Yes No
Signature of Applicant Date
Have you ever been
arrested, charged with, or convicted of driving under the influence
?
Yes No
Signature of Applicant Date
If the answer to any of the three questions above is YES, please attach a full explanation including date,
location, charge(s), disposition, court, and the law enforcement agency having jurisdiction. If you answered
yes, and the charges have been dismissed, please attach a copy of the court document.
IN 1542 / RDA 1493 (Rev. 5/2015)
Application
for Basic Law
Enforcement
School
(continued)
Page
3
In order to remain in compliance with the Tennessee Peace Officer Standards and Training Commission
(POST) every incoming student/cadet must indicate if they have previously attended a state academy.
According to POST Rule number 1110-2(4)a, b, c, Application Requirement. No officer shall be certified under
these rules unless application is made at such time and in such form as the Commission may require (T.C.A.
§38-8-104).
Have you ever attended, withdrawn, or been dismissed from any other Tennessee POST approved
law enforcement training academy.
Yes No
I, under the penalty of perjury (T.C.A. §39-16-701), certify that the information provided in this
application is correct and complete.
I have disclosed in this application all instances where I have been arrested and/or convicted of any
crime other than a traffic violation. This includes all instances where the original charges were
reduced, where the conviction or arrest was a result of a plea bargain, a jury trial, or a bench trial, or
where charges were dropped after the successful completion of pre-trial diversion.
I certify
that the
information
given in this
application
is correct and complete to the best of
my
knowledge,
and if I
am
approved, I
will
abide by the rules and
regulations
of the Academy.
Signature
of
Applicant
Date
THE FOLLOWING IS TO BE COMPLETED BY THE APPLICANT'S
EMPLOYMENT AGENCY
HEAD
I
certif
y
that the above
information
is
correct
and the applicant is a full-time
law
enforcement
officer
employed
by my department and hereby approve the applicant to
attend
Basic Law Enforcement
School.
Any person who, with intent to deceive, makes any false statement on this
document
commits
the
offense of perjury
pursuant
to T.C.A. §39-16-702.
Signature
Title
Department
Mailing Address
City/State
Zip Code
Phone # Fax #
E-Mail
Today’s Date
FAILURE OF THE APPLICANT THE APPLICANT’S DEPARTMENT/AGENCY TO COMPLETE AND SIGN
ALL APPLICABLE AREAS OF THIS APPLICATION WILL RESULT IN THE APPLICANT BEING DENIED
ACCEPTANCE INTO THE BASIC POLICE SCHOOL.
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APPLICATION FOR BASIC LAW ENFORCEMENT SCHOOL TENNESSEE LAW (Maury County Government)

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Completed 14 February 2021

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