Proposed Method of Payment: Self Pay VA Assistance Financial Aid Bright Futures Florida Prepaid Paid Agency Sponsor/Agency Name:

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1 Recruit Application Applicant Name: Street Address: Daytime telephone: Cell phone: Sex: Race: Social Security #: BAT Score: Desired Class: Law Enforcement Basic Recruit Program (Day Class) Law Enforcement Basic Recruit Program (Night Class) Correctional Basic Recruit Program (Day Class) Correctional Basic Recruit Program (Night Class) Correctional Probation Training Program Cross-Over Correctional to Law Enforcement Program Cross-over Law Enforcement to Correctional Program Cross-Over Correctional to Correctional Probation Program Law Enforcement Auxiliary Officer Basic Recruit Course Proposed Method of Payment: Self Pay VA Assistance Financial Aid Bright Futures Florida Prepaid Paid Agency Sponsor/Agency Name: Notification of Social Security Number Collection and Usage In compliance with FL Statute , this document serves to notify you of the purpose for the collection and usage of your Social Security number. Tallahassee Community College collects and uses your social security number only in performance of the College s duties and responsibilities. To protect your identity TCC will secure your social security number from unauthorized access, never release your social security number to unauthorized parties, and assign you a unique student or employee identification number. This unique identification number is used for all associated employment and educational purposes at TCC. Page 1 of 11

2 PAT THOMAS LAW ENFORCEMENT ACADEMY TALLAHASSEE COMMUNITY COLLEGE DECLARATION FORM All statements and information given in this application are true to the best of my knowledge. In the event that I am admitted to the Academy, I understand that any information found to be omitted or incorrect on any portion of my application may constitute grounds for dismissal. By my signature below, I hereby authorize the Pat Thomas Law Enforcement Academy to conduct such investigations as are necessary to determine the accuracy and completeness of this application. Signature Date Before me personally appeared signed the above document on (Name) (Date), who in my presence,. The applicant produced the following identification personally known by me. (Type of Identification) or is Notary s Name: Notary s Signature: Date: SEAL NOTICE TO APPLICANTS: This document shall constitute an official statement within the purview of Section , Florida Statutes, and is subject to verification by Pat Thomas Law Enforcement Academy, employing agency, and/or the Florida Criminal Justice Standards and Training Commission. Any intentional omission when submitting this application or false execution of this affidavit shall constitute a misdemeanor of the second degree and may disqualify you from employment as a law enforcement or corrections officer in the State of Florida. Page 2 of 11

3 ACADEMY FINANCIAL AID AND REFUND DISCLOSURE FORM As an applicant for a recruit training program at the Tallahassee Community College (College) Pat Thomas Law Enforcement Academy you are applying for a program of study made up of several individual courses offered to the cohort of students that begin the program together. Each of those courses must be successfully completed in order to continue in the program and the program in its entirety must be successfully completed in order to be eligible to take the State Officer Certification Exam prior to employment in Florida as a law enforcement, corrections, or correctional probation officer. No students may be added to the program by enrolling after the program begins. Therefore, no refunds for courses enrolled in but not taken or successfully completed as part of the entire program will be made after the first five days of the program. If you are a student who receives Title IV student financial aid (Federal Pell Grants, Federal SEOG, Federal Stafford Loans or PLUS Loans) and you withdraw, are dismissed, or your classes are canceled for any reason, your financial aid will be reviewed by the College under the Federal Return to Title IV policy, as required by the Federal Government. Students who withdraw or are dismissed and who receive Title IV Federal financial aid may owe the Federal Government, TCC, or both, money based on the determination of the Federal review. These funds would be in addition to any tuition you may owe. If you have any questions about your potential financial liability, you are directed to contact the College s Financial Aid Office for assistance before enrolling in this program. Your signature below acknowledges you have read and understand your financial obligations as described above. Date Applicant Signature Page 3 of 11

4 INSTRUCTIONS FOR FILLING OUT BASIC RECRUIT APPLICATION You are about to take the most important step toward an exciting and rewarding career anyone can take. The following pointers will help you succeed in gaining acceptance at the Pat Thomas Law Enforcement Academy. You must first the Criminal Justice Abilities Test (CJBAT) for your area (Law Enforcement or Corrections) prior to acceptance to the academy. To set up an appointment for testing, please call the Tallahassee Community College Testing Center at (850) The cost for this test is $ When filling out this application, please type or print legibly in black ink. Fill out the application in its entirety. Any omitted information may disqualify you from acceptance to the Academy. If you have questions about whether to include any information requested, contact Academy staff for guidance. Obtain a Level II criminal background check for State (FDLE) & Federal (FBI) via an FDLE approved vendor and sent to our ORI (FL922480Z). A list of FDLE approved vendors may be located at: History/Livescan-Service-Providers-and-Device-Vendors.aspx Fees for the Level II criminal background checks are set by the vendors. Then you must return the completed application with a $50.00 application fee (nonrefundable). Checks should made payable to the Tallahassee Community College. Remove the physical form from this application packet and keep it until you are notified whether or not you have been accepted. If accepted to the Academy, you will be instructed to take the CJSTC form 75B to a licensed physician for completion. When turning in your application, make sure that all necessary documentation is attached with the application. (See next page for checklist) Please fill out the application carefully and recheck it for any omissions or mistakes. Incomplete applications are not acceptable and shall not be processed. If any of the necessary documentation that is required to be turned in with the application is unavailable at the time you submit your application, please make note of it on the comments form, stating when you expect to obtain the information and turn it in. Page 4 of 11

5 APPLICATION CHECKLIST 1. The following items must accompany your application at the time you submit it. Declaration Form (included in this packet) Basic Abilities Test results (obtained from TCC Testing Center) 7-year Driving History (obtained from DHSMV) Copy of Drivers License Copy of High School Diploma/GED and College Degree, if earned (Transcripts are acceptable)(official transcripts are required for financial aid) Copy of Birth Certificate Copy of Social Security Card Copy of Military Record (DD214) if applicable Completed FDLE Criminal History via Livescan vendor sent to our ORI (FL922480Z). Completed Personal History (included in this packet) 2. Please note that if you your court record indicates you have been arrested for a drug offense you may be required to submit to a drug test, at your expense, at a designated medical facility prior to admission into the Academy. 3. Return your application with the documentation required to the Academy at one of the following addresses based on law enforcement or corrections programs: PAT THOMAS LAW ENFORCEMENT ACADEMY PAT THOMAS LAW ENFORCEMENT ACADEMY LAW ENFORCEMENT COORDINATOR CORRECTIONS COORDINATOR 75 COLLEGE DRIVE 75 COLLEGE DRIVE SUITE 203 SUITE 203 HAVANA, FL HAVANA, FL Page 5 of 11

6 PAT THOMAS LAW ENFORCEMENT ACADEMY TALLAHASSEE COMMUNITY COLLEGE INFORMATION RELEASE FORM Applicant: Date of Birth: Social Security #: To Whom It May Concern: I am an applicant for admission to the Pat Thomas Law Enforcement Academy in a training program. In order for the Pat Thomas Law Enforcement Academy (Academy) to conduct a comprehensive investigation prior to my admission it may be necessary for certain information that might otherwise be confidential to be released to them. Further, I hereby acknowledge that if I am accepted for admission it may also become necessary for the Academy to conduct an investigation of me during my Academy class. This release authorizes disclosure of records including, but not limited to, education records, medical records, employment records and credit records to representatives of the Academy at any time prior to the scheduled graduation date of my class from the Academy. By copy of this form, I hereby authorize the release (including duplication of records) to representatives of the Pat Thomas Law Enforcement Academy of any and all records concerning me you may hold. Signature of Applicant Date Page 6 of 11

7 PAT THOMAS LAW ENFORCEMENT ACADEMY APPLICATION FOR BASIC RECRUIT POSITION Please print neatly in black ink or type. PERSONAL HISTORY 1. Full Name: Last First Middle 2. Have you ever had your name changed? Yes No If you answered Yes to question #2, indicate as follows: A. Previous Name: B. Date and location of change: _ C. Reason for change: 3. Present address: Street, P.O. Box City State Zip 4. Home Phone: Business: _ Other: 5. Age: Date of Birth: Place of Birth:_ 6. Weight: Height: Color Hair: 7. Driver s License#: State: Expiration: 8. Are you currently: Married: Separated: Divorced: Single: 9. Full name of spouse Last First Middle 10. Name of person(s) to notify in the case of emergency: 1. Name Relationship Home Phone Work Phone 2. Name Relationship Home Phone Work Phone Page 7 of 11

8 11. List below any current or previous family member who was employed as a law enforcement/corrections officer: A. Name Relationship Agency Home Phone Work Phone B. Name Relationship Agency Home Phone Work Phone CITIZENSHIP INFORMATION 1. Are you a citizen of the United States? Yes No 2. Naturalization: Date: Location: Number: CERTIFICATION REFERENCE INFORMATION 1. Are you presently certified or have you ever been certified as a law enforcement or corrections officer? Yes No If yes, date certified: State: 2. If not presently working as a law enforcement/corrections officer, date last worked as such: Date: Agency Name: 3. Number of years and months experience as a law enforcement/corrections officer: Years: Months: EDUCATION 1. Do you have a college or university degree? Yes No 2. Please check highest degree: AA/AS BA/BS MA/MS PhD/JD 3. Number of semester hours: Quarter hours: 4. Major: Minor: LAW ENFORCEMENT EXPERIENCE Agency Phone Number Rank Date Employed Supervisor Page 8 of 11

9 EMPLOYMENT REFERENCES OTHER THAN LAW ENFORCEMENT EXPERIENCE List chronologically the last two employers, including part-time: 1. Name of Employer Dates Employed (From/To) Position Held Address City State Zip Name of Supervisor Telephone Number Reason for Leaving 2. Name of Employer Dates Employed (From/To) Position Held Address City State Zip Name of Supervisor Telephone Number Reason for Leaving Have you ever applied for a position with or been sponsored into basic training by any criminal justice agency? If yes, please list below: Agency Date Agency Date COURT RECORD 1. Have you been given a traffic ticket within the past five- (5) years? Any civil infractions? Yes No If yes, please list: Date Place Charge Page 9 of 11

10 COURT RECORD CONTINUED 3. Have you ever been arrested or charged in any state for any criminal violation (felony or misdemeanor or contempt of court order?) Yes No If yes, list all charges below: (please use additional pages if necessary) Date Place Charges If convicted, has your record been expunged or sealed? Yes No If yes, please provide the following information: (note: use additional page if necessary) Date: City: County: State: (If you have a sealed or expunged record that you have not disclosed in this application, you may not be eligible for employment or appointment as a criminal justice officer.) If you have doubts or questions about a sealed or expunged record affecting your employability, it is your responsibility to review FSS &.14 for employment eligibility requirement. (Please answer the following in your own words.) ESSAY PORTION WHY DO YOU WANT TO BECOME A CRIMINAL JUSTICE OFFICER? Page 10 of 11

11 Use this page to list any additional information. COMMENTS FORM SPECIAL NOTE: This page should also be used to list any pre-existing injuries you may have that may be aggravated by physical exercise or activity. Pre-existing injuries of a serious nature (back injuries, recent surgery, joint injuries or disease, etc.) must be medically cleared prior to participating in any physical activity or training. This should also include any other medical conditions that would place you or anyone else at risk during the academy. Page 11 of 11