Law Enforcement Agency (Lea) - Application For Participation Form
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LAW ENFORCEMENT AGENCY (LEA)
APPLICATION FOR PARTICIPATION
*This application must be updated and resubmitted within 30 days of any changes or on an annual basis
NEW
UPDATE
SCREENER ID (Update Only):____________________
AGENCY:____________________________________________________________________________________
PHYSICAL ADDRESS (No P.O. Box):_____________________________________________________________
MAILING ADDRESS (If different than above): ______________________________________________________
CITY:__________________________________________________ STATE:_______________________________
ZIP:____________________________EMAIL:_______________________________________________________
PHONE:___________________________________________FAX:______________________________________
NUMBER OF COMPENSATED OFFICERS WITH ARREST AND APPREHENSION AUTHORITY
FULL-TIME: ___________
PART-TIME: ___________
RESERVE: ___________
SCREENER(S) POC: MUST HAVE AT LEAST ONE
*MAIN POC: Designated POC for calls and emails on 1033 Program requests and property pickup
SCREENER/MAIN POC: ________________________________________________________________________
SCREENER/POC #2: ___________________________________________________________________________
SCREENER/POC #3: ___________________________________________________________________________
SCREENER/POC #4: ___________________________________________________________________________
WEAPON POC (Optional):_______________________________________________________________________
AIRCRAFT POC (Optional):_____________________________________________________________________
INVENTORY CHECK
Does the Agency currently have any equipment from the 1208/1033 Program? YES
NO
WEAPONS:
YES
NO
AIRCRAFT:
YES
NO
WATERCRAFT:
YES
NO
TACTICAL:
YES
NO
OTHER CONTROLLED:
YES
NO
DEMIL A :
YES
NO
VEHICLES
PROPERTY
(LESS THAN A YEAR OLD)
*By signing this application, the Chief Executive Official/Head of Agency (Local Field Office) is aware of
1208/1033 Property currently in the possession of their department.
*Upon acceptance into the 1033 Program, I understand that I have 30 days to familiarize myself with the
State Plan of Operation and all 1033 Program guidance that is provided by the State Coordinator and that by
signing, I certify that all information contained above is valid and accurate.
CHIEF EXECUTIVE OFFICIAL/:
_______________________________________ DATE:___________
HEAD OF LOCAL AGENCY
PRINTED NAME
_______________________________________
SIGNATURE
STATE COORDINATOR:
_______________________________________ DATE:___________
(NOT REQUIRED FOR FEDERAL)
P
RINTED NAME
_______________________________________
SIGNATURE
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