Initial Employment (Form 21) - Virginia Department Criminal Justice Services
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1Commonwealth of Virginia
Virginia Department of Criminal Justice Services
Initial Employment (Form 21)
Submit to: Department of Criminal Justice Service, 1100 Bank Street, 12
Floor, Richmond, VA 23219 to be
th
entered into the T-REX Training Records System within 10 days of officer employment
Officer’s Current Name: (Last, First, Middle Initial)
Social Security Number:
Date of Birth (mm/dd/year):
Gender (Optional for statistical purposes only)
Female
Male
Appointing Agency/Department:
Employment Date: (mm/dd/year)
Rank:
Check the correct status:
Designate Primary Function: (Designate below the primary function the
officer will perform by checking one only)
Law Enforcement Officer
Full time
Jail Officer/Deputy
Part-time (Compensated more than 80 hours annually)
Court Security Officer
Auxiliary Level One
Civil Process Officer
Auxiliary Level Two
Communications Officer/Dispatcher
Auxiliary Level Three
DOC Corrections Officer
DJJ Juvenile Corrections Officer
Instructor Only
For Secondary Functions: Please list all secondary functions for
Education:
which you will require training and certification:
Less than high school
Law Enforcement Officer
High school or equivalent
Jail Officer/Deputy
Some college
Communications Officer
Associate Degree
Court Security Officer
Four Year Degree
Civil Process Officer
Post Graduate Degree
§ 15.2-1705, Code of Virginia, requires all police officers, deputy sheriffs, law enforcement officers and regional jail officers, defined in § 9.1-
101, Code of Virginia, to meet minimum employment qualifications prior to employment. Is this officer in compliance with § 15.2-1705, Code
of Virginia (1950), as amended?
Yes
No (If No, you must submit Form W-1 “Application for Waiver of Minimum Qualifications.”
Attest: I CERTIFY that the above statements are true and correct to the best of my knowledge and that I am authorized to submit this
information. (Print or type name and Sign Form)
Submitted by: ________________________________________________ Title:_______________________________ Date: ____________
Signature:________________________________________________________________ Telephone: _______________________________
Retain a signed copy for your records as a copy may be requested by the Department of Criminal Justice Services if errors are found.
Virginia Department of Criminal Justice Services
September 2013
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