Personnel Change-In-Status Report
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1
2Form F-4
COMMISSION ON LAW ENFORCEMENT STANDARDS AND TRAINING
PERSONNEL CHANGE-IN-STATUS REPORT
This form should be completed and returned to the Commission on Law Enforcement Standards and Training within
ten (10) days of action.
Reporting Agency:
Date:
(Month/Day/Year)
Agency Contact Number:
Officer's Name:
(Rank/First/MI/Last Name/Badge #)
SSN #:
DOB:
Date Employed:
(Month/Day/Year)
(Month/Day/Year)
Status:
Full-Time
Auxiliary law Enforcement Officer
Part-Time I
Specialized Police Personnel
Part-Time II
Other - Specify
CHECK ONE
TYPE OF ACTION
DATE OF ACTION
(Month/Day/Year)
Resigned-Reason:
(Do you recommend decertification?
Yes
No)
Dismissed-Reason:
(Do you recommend decertification?
Yes
No)
If separated for a reason listed under Arkansas State
Statute 12-9-602(b)(2), please check the correct
paragraph and attach a statement of facts:
A
B
C
D
Other Reason-(Specify):
Change in Rank-From:
To:
Name Change From:
To:
I hereby attest to the best of my knowledge the information submitted on this form is true and correct.
Form Completed By:
Title:
(Rank/First/MI/Last Name/Badge #)
SWORN AND SUBSCRIBED BEFORE ME
NOTICE: False swearing is a Class A
misdemeanor. Punishable under Arkansas
Code 5-53-103.
NOTARY PUBLIC, THIS
DAY
OF
,
20
MY COMMISSION EXPIRES
NOTE: PRINTED ON THE REVERSE SIDE OF THIS FORM IS PARAGRAPHS A, B, C, AND D OF ARKANSAS
STATE STATUTE 12-9-602(b)(2).
Revised 06-03
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