LEA-PST Revised 10-05-12
New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505)
82
7-9251(877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us
/
PUBLIC SAFETY TELECOMMUNICATOR TRAINING PAPERWORK CHECKLIST
The following documents must be submitted for enrollment in the New Mexico Department of Public
Safety Training Center’s Basic Public Safety Telecommunicator Training Program, OR New Mexico
Regional Academy Public Safety Telecommunicator Graduate Program. Incomplete applications will be
returned.
ITEMS REQUIRED ITEMS REQUIRED BY ALL APPLICANTS PPLICANTS
Form No. LEA-1 - Application for Admission/Certification.
Form No. LEA-3A - PST Audiology Compliance Form.
Form No. LEA-5 - Fingerprint Affidavit. Form must have original signatures. Submit only after FBI and
DPS clearances have been re
ceived.
Form No. LEA-6 - Applicant Affidavit. Form must have original signatures.
Form No. LEA-7 - Mental, Physical, Emotional Certification by department head. Form must have original
signatures.
Form No. LEA-8 - Waiver of Liability. Form must have original signatures.
Form No. LEA-9 - Release of Information. Form must have original signatures.
Form No. LEA-10 - Employment Verification. Form must have original signatures.
Form No. LEA -12- Applicant Affidavit of United States citizenship or legal residency or proof U.S.
citizenship iss
ued by an official government agency. Hospital birth records and baptismal records
are not
acceptable. P
hotocopies of birth certificates and naturalization papers are not legal under New Mexico Law.
Form No. LEA-82 - Agency Employment Action. Form must have been previously submitted or attached to
this application.
Notarized copy of high school diploma, G.E.D. certificate or college diploma, or official/certified transcripts.
Notarized copy of DD214 form (if applicant has had military service) must have character of
service.
Purchase Order for tuition.
Notarized copy of Handicap Statement.
Mail Entire Packet to:
New Mexico Department of Public Safety
Training Center, ATTN: Basic Bureau
4491 Cerrillos Road, Santa Fe, NM 87507
DPS Use
Only: DPS Use Only:
Basic Bureau Review by:_________________________________________ Date_________________
Regional Academy Review by: ___________________________________ Date _________________
Incomplete - Returned to agency/academy Date returned:_____________________________
Approved by Deputy Director Date approved:____________________________________________
Date Permanent file created:_________________________________ File number_________________
Skills manger profile created by__________________________ Date___________________________
Profile creation pending. Reason:________________________________________________________
Academy Location:________________________
Academy Dates___________________________
New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505) 827-9251(877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us/
Revised 01-17-12
LEA-1
BASIC TRAINING AND RE-CERTIFICATION REQUEST
CHECK APPROPRIATE CATEGORY
Law Enforcement Officer Public Safety Telecommunicator
NMDPS Basic Training
Certification by Waiver of Previous
Training
Previously New Mexico Certified
Previously Certified in another State
NM Regional/Satellite Academy
NMDPS Basic Public Safety
Telecommunicator Training
Certification by Waiver of Previous
Training
NM Regional/Satellite Academy
Please type or print all information. Incomplete applications will be returned.
Name:
Last First Middle Maiden
Date of Birth:
Place of
Birth:
Social Security
Number:
Race:
Sex:
Applicant Mailing
Address:
Street or P.O. Box
(Applicant Telephone Number)
( )
City State Zip
AGENCY NAME:
Agency Contact
Person:
Name/Title: Telephone Number
Agency Mailing
Address:
Street or P.O. Box
City State Zip
Date of Employment:
________________
Date of L.E. Commission:
____________________________
Job Title:
__________________________
I certify that the foregoing information supplied by me is true and correct.
_______________________________ ______________________
Applicant Signature Date
DPS Use Only
Registry Input Processed By_______
Certification #:__________________
DPS Use Only
Training Processed By ____________)
Permanent File#:____________________)
Retired Law Enforcement Officer:
Yes No
click to sign
signature
click to edit
New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505)
82
7-9251(877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us/
Revised 01-17-12 LEA-3A
PUBLIC SAFETY TELECOMMUNICATOR
AUDIOLOGY COMPLIANCE FORM
Applicant Name ( Last, First, Middle)
SECTION ONE Ears and Hearing
Minimum
Hearing Standards for Public Safety Telecommunicator
No Uncorrected hearing loss in either ear greater than 25db at the test frequencies,
500, 1000, and 2000 Hz, and
No more than a 20db loss in the better ear by audiometry, using ANSI(1969) standards.
Hearing Acuity ( Audiogram Required) Record the values at each Hz level
Right (Decibels) Left (Decibels)
(Hertz) 500  (Hertz) 500 
1000  1000 
2000  2000 
Excludable Condition
Acute Otitis Media, Otitis Externa, and Mastoiditis
Excludable Condition
Statement of Condition
The applicant has passed the minimum standards as established by the New Mexico Law Enforcement Academy
Board without exclusions.
The applicant has one or more potentially excludable conditions from the listed minimum medical standards as
established by the New Mexico Law Enforcement Academy Board, but can perform the functions of a
telecommunicator with accommodations. (Please explain below.)
The applicant has one or more potentially excludable conditions from the listed minimum medical standards as
established by the New Mexico Law Enforcement Academy Board, and cannot perform the functions of a
telecommunicator. (Please explain below.)
I have personally examined the applicant and the listed results are correct.
Audiologist Physician Other___________________
____
_____________________________________________________________ _________________________
Name of Examiner (Please Print) NM Lic. #
_________________________________________________________________ _________________________
Signature Date
Comments:_____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________
I certify that on this date _________________ a finger print check through NMDPS Records,
FBI R
ecords and a NCIC TRIPLE I Clearance has been received and reviewed for compliance.
Records are valid for one year from the date of initial clearance.
Do not send printouts or copies of printouts with this form.
Department: ___________________________________________________________
Department Head Name: _________________________________________________
Department Head Signature: _______________________________________________
State of New Mexico}
County of _______________} SS
On this ____________day of _____________, ________, before me personally
Appeared____________________________________known to me to be the person whose
name is subscribed to the above instrument and acknowledged the same to be his/her own
free act and deed.
Notary Public________________________________My commission expires:_________
The applicant will not receive state certification until this form is received.
(SEAL)
Revised 06/14/2016
New
Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa
Fe, New Mexico 87507
(505) 827-9252 (877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us
FINGERPRINT AFFIDAVIT
(refer to 10.29.9.13 or 10.29.10.11 NMAC)
I certify that fingerprint cards for ___________________________________were
Please Type or Print Applicant Name
submitted to New Mexico Applicant Processing Services
(https://www.cogentid.com/nm/index_NM.htm) either electronically or by mail, for both the
Federal Bureau of Investigation and the New Mexico Department of Public Safety records
check. It was determined that the applicant has not been:
Convicted of or pled guilty to, or entered a plea of nolo contendere to any felony charge
or, within the three-year period immediately preceding their application, to any violation
o
f any federal or state law or local ordinance relating to:
o Aggravated assault, theft, o Driving
while intoxicated, o Controlled
substances or o Other crime
involving moral turpitude
o Has not been released or discharged
under dishonorable conditions from
any of the armed forces of the United
States.
New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505) 827-9251(877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us/
Revised 01-17-12 LEA-6
APPLICANT AFFIDAVIT CRIMINAL HISTORY
Have you ever been arrested? (Include juvenile offenses) (Attach separate pages if necessary.)
Yes No If yes, explain charge, circumstance and date of occurrence along with attaching
offense/incident reports and court record of final disposition:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Have you ever been convicted of any crime?
(Attach separate pages if necessary.)
Yes No If yes, explain charge, circumstance and date of occurrence along with attaching
offense/incident reports and court record of final disposition.
____________________________________________________________
____________________________________________________________
____________________________________________________________
Have you ever been pardoned, entered into a pre-prosecution diversion program, or received a suspended or
deferred sentence for any crime?
Yes No If yes, explain charge, circumstance and date of occurrence along with attaching
offense/incident reports and court record of final disposition.
____________________________________________________________
____________________________________________________________
____________________________________________________________
Have you ever been the subject of an administrative investigation for law enforcement officer, or
telecommunicator misconduct, or received any administrative discipline as a law enforcement officer? (Attach
separate pages if necessary.)
Yes No If yes, explain charge, circumstance and date of occurrence:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Have you ever served in the armed forces of the United States?
Yes No If yes, attach a notarized copy of DD214 with character of service.
I certify the above is true and correct to the best of my knowledge.
Applicant Name ________________________________________ Date of Birth_______________________
(Print name)
Applicant Signature _________________________________
State of New Mexico }
County of __________________}SS
On this ____________day of _______________, _________, before me personally appeared
________________________________________known to me to be the person whose name is subscribed to
(Applicant)
the above instrument and acknowledged the same to be his/her own free act and deed.
Notary Public _______________________________ My commission expires:________
(SEAL)
click to sign
signature
click to edit
New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505) 827-9251(877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us/
Revised 01-17-12 LEA-7
TELECOMMUNICATOR MENTAL, PHYSICAL, EMOTIONAL
CERTIFICATION
I, ____________________________________certify that to the best of my knowledge
Please type or print Department Head
______________________________________is free of any mental, physical, or
Applicant
emotional condition which might adversely affect his/her performance as a
telecommunicator.
Department Head Signature_____________________________________________
State of New Mexico }
County of _______________}SS
On this ____________day of _____________, ________, before me personally
appeared____________________________________known to me to be the person
Department Head
whose name is subscribed to the above instrument and acknowledged the same to be
his/her own free act and deed.
Notary Public________________________________My commission expires:_________
(SEAL)
New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505) 827-9251(877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us/
Revised 01-17-12 LEA-8
WAIVER OF LIABILITY
Applicant Name (Please Print)_______________________________________________
Home Address ________________________________________________
Home Telephone No. _______________________
Next of Kin ________________________Relationship_____________
I, the undersigned, hereby waive any claim for any injury against the New Mexico
Department of Public Safety Training Center, any member of the staff, any of its
employees or any trainee, which I may either directly or indirectly sustain as a result of
my participation in any part or phase of the training and instruction I will receive at the
Training center or other locations selected for the giving of training or supervision. This
agreement shall be binding upon the undersigned, his heirs, and assignees.
Signature of Applicant________________________________________________
State of New Mexico }
County of __________________}SS
On this ____________day of _______________, ________, before me personally
Appeared ________________________________________known to me to be the person
Applicant
whose name is subscribed to the above instrument and acknowledged the same to be
his/her own free act and deed.
Notary Public _______________________________ My commission expires:________
(SEAL)
click to sign
signature
click to edit
New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505) 827-9251(877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us/
Revised 01-17-12 LEA-9
RELEASE OF INFORMATION
To Whom It May Concern:
Having made application with New Mexico Department of Public Safety Training
Center, it is my understanding that a comprehensive investigation of my background may
be conducted in connection with this application.
I do hereby give the officials of the Training Center the authority to conduct such an
investigation and do hereby authorize the release of any and all information requested by
the Training Center pertaining to my work history, any arrest information, and other
general qualifications for fitness.
Applicant Name ________________________________
Please Print
Signature of Applicant_________________________________________________
State of New Mexico }
County of __________________}SS
On this ____________day of _______________, ________, before me personally
appeared ________________________________________known to me to be the person
Applicant
whose name is subscribed to the above instrument and acknowledged the same to be
his/her own free act and deed.
Notary Public _______________________________ My commission expires:________
(SEAL)
New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505) 827-9251(877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us/
Revised 01-17-12 LEA-10
TELECOMMUNICATOR EMPLOYMENT VERIFICATION
I, ___________________________________________________________certify that
Please type or print Department Head Name
_____________________________________________________________ was
Applicant Name
employed as a Telecommunicator with my agency on ______________________and
Month Day Year
is responsible for emergency telecommunicator duties.
Department Head Signature ____________________________________________
State of New Mexico }
County of __________________}SS
On this ____________day of _______________, ________, before me personally
Appeared ________________________________________known to me to be the person
Department Head
whose name is subscribed to the above instrument and acknowledged the same to be
his/her own free act and deed.
Notary Public _______________________________ My commission expires:________
(SEAL)
New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505) 827-9251(877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us/
Revised 01-17-12 LEA-12
APPLICANT AFFIDAVIT
of
UNITED STATES CITIZENSHIP (
Law Enforcement Officers)
or LEGAL RESIDENCY (Telecommunicators only)
APPLICANT
I certify that I am a citizen of the United States of America or a legal resident. Official
documentation of my citizenship or legal residency has been presented to the witness, who
is the agency head or designee.
Applicant Name:_____________________________________
Please print or type.
Applicant Signature:________________________________________________
WITNESS (Agency head or designee)
I certify that I have reviewed official documentation indicating the above applicant is a
citizen of the United States of America or legal resident.
Witness Name:_______________________________________
Please print or type.
Witness Signature:_________________________________________________
Type of documentation:
Birth Certificate (Must be issued by a government agency)
Issued by:__________________________________________ Document #____________________
Passport
Issued by:__________________________________________ Document #____________________
Naturalization Papers
Issued by:__________________________________________ Document #____________________
Resident card or Paperwork (for telecommunicators only)
Issued by:_________________________________ Document #____________________
State of New Mexico }
County of______________________}SS
On this ________ day of ______________,________, before me personally appeared
__________________________ and ___________________________ known to me to
Applicant Witness
be the persons whose names are subscribed to the above instrument and acknowledged the
same to be his/her own free act and deed.
Notary Public:______________________________ My commission expires:__________
(SEAL)
New Mexico Department of Public Safety Training Center
4491 Cerrillos Road, Santa Fe, New Mexico 87507
(505) 827-9251(877) 237-7532 (NM Only) Fax: (505) 827-3449 http://nmlea.dps.state.nm.us/
Revised 01-17-12
LEA-82
Agency Employment Action
Date of Action:_________________________________________
Employment (new hire) Promotion
Separation/Other Action: (*if resigned or terminated due to misconduct submit LEA-90 form)
Submitted by ___________________________________Signature_______________________________
Chief/Designee
Date __________________________________________ Title or Rank______________________
Agency________________________________________ Telephone________________________
Employee Information
Name________________________________________________________________________________
First Middle Last Maiden
Address______________________________________________________________________________
Date of Birth__________________SS#________________________________Gender ______________
Ethnic Orgin_________________________________Rank or Classification _______________________
Date of Current Employment____________________Date of Current Commission __________________
DPS Certification Number _______________________Certification Date _____________________________
Entry Level Firearms Training/Qualification (For new hires without active certification)
ENTRY LEVEL FIREARMS TRAINING/QUALIFICATION (10.29.9.14)
Sixteen (16) hour handgun training: Eight (8) hour shotgun training (if issued):
Day Time Score: Date:_____________ Night Time Score: Date:___________
________________________________________ ________________________________
Print Name of DPS Certified Firearms Instructor DPS Certification Number
Instructor Signature ____________________________Contact #______________________________
DPS Use Only: Permanent File #________________________
Registry input by:: Certification Verified by: Firearms Qual. Processed by:
__________________ ____________________ ______________________
Deceased Military Retired Resigned* Terminated* Misconduct*
Decommissioned Only Medical________________________________________
Other_________________________________________________________________
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