BROWARD SHERIFF’S OFFICE
CITIZEN OBSERVER PATROL
MEMBER APPLICATION FOR
Last (Family) Name: First Name: Full Middle Name(s):
BSO District Applying To: Maiden Name: Previous Names:
Applicant Signature: Today’s Date:
Background/License
Checked by:
Print Title & Name: Signature & CCN: Date:
Use reverse for additional information from boxes. Applicants return this form to their respective district coordinator/office.
Applicants or processors should attach a photocopy of the driver=s license or other identification to this form.
COP #20 (Revised 05/17)
Address in
Florida
Street/Apartment: City/Zip Code:
Telephone
Numbers
Home: Office: Others (Cellular):
Race: Sex: Date of Birth:
Social Security #:
Height & Weight
Emergency
Contact
Name: Address: Telephone Number(s):
Email Address:
Driver’s
License
State/Province
Issued:
Driver’s License Number: Telephone Number(s):
Do You Having Any Driving
Restrictions?
Yes
No
If Yes, Explain:
Have you ever been arrested?
Yes
No If Yes, explain:
Do you have any physical defects,
handicaps, or other disabilities
which could affect you as a COPs
volunteer?
Yes
No If Yes,
explain:
I hereby certify that all statements made by me on this application are true, complete, and correct to the best of my knowledge. I
understand that a background check will be made upon submission of this application. I understand that any criminal conviction, any
previous actions which may reflect unfavorably upon the Broward Sheriff’s Office, any attempt to deceive or conceal pertinent
information, or any suggestion I may be a security risk may be cause for membership denial or dismissal. I give full and unqualified
permission to the Broward Sheriff’s Office to make any and all inquires into my present and past personal and business status as may be
deemed necessary in the interest of the Sheriff’s Office and my appointment therein. I understand the Broward Sheriff’s Office Citizen
Observer Patrol is a volunteer organization and I will receive no compensation for membership.
