BROWARD SHERIFF=S OFFICE
CITIZEN OBSERVER PATROL
MEMBER APPLICATION FORM
Last (Family) Name:
First Name:
Full Middle Name(s):
BSO District Applying To:
Maiden Name:
Previous Names:
Race: Sex: Date of Birth: Social Security Number: Height & Weight:
Emergency
Name: Address:
Telephone number(s):
Contact
L
Address in
Street/Apartment: City/Zip Code:
Florida L
Telephone
Home: Office: Others (cellular/pager/etc):
Numbers
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 (New 11/96)
Driver License(s):
State/Provin
ce Issued:
Driver=s
License
umber:
Driver=s
License L
N
Do You Having Any Driving
Restrictions? Yes No
Have you
ever been
arrested?
Do you have any physical defects, handicaps, or other
disabilities which could affect you as a COPs volunteer?
If AYes,@ Explain:
Yes No If
AYes,@
explain:
Yes No If AYes,@ 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.
