Notice Of Employment Or Termination Form
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1NOTICE OF EMPLOYMENT / TERMINATION
Forward to the MCJA within 30 days of employment or termination
Please fill out either the EMPLOYMENT or the TERMINATION information, as applicable.
Name (Applicant) ________________________________________________ Maiden Name___________________
(Last)
(First)
(Middle)
Department___________________________________________________
Title___________________________
Department email address: ______________________________________________________________________
Date of Birth: _______________________
Sex: ________
SS# __________________________
The following statement is made pursuant to the Privacy Act of 1974, §7(b): Disclosure of your social security number is mandatory. Solicitation of your social
security number is solely for tax administration purposes pursuant to 36 MRSA §175 as authorized by the Tax Reform Act of 1976 (42 USC, §405(c)(2)(C)(i) and
for child support enforcement purposes pursuant to 42 USC § 666(a)(13)(A) and 19-A M.R.S.A. §§2104, 2201. Your social security number will be disclosed to
the State Tax Assessor or an authorized agent for use in determining filing obligations and tax liability pursuant to Title 36 of the Maine Revised Statutes and/or
to the Department of Human Services Division of Support Enforcement and Recovery for use in child support enforcement procedures. No further use will be
made of your social security number. It shall be treated as confidential tax information pursuant to 36 MRSA §191 and confidential support enforcement
information pursuant to 19-A MRSA §2152.
**********************************************************************************************************************************
EMPLOYMENT DATE: ____/____/____
IS THIS A BLETP CANDIDATE
YES
NO
IS THIS A BCOR CANDIDATE
YES
NO
Has this individual been employed as a Maine Law Enforcement/Correction officer within the past two years? YES
NO
**If no and individual has not worked as a LEO or CO within the past two years , then individual must be recertified.**
:
EMPLOYMENT LEVEL
Full Time Law Enforcement
Part Time Law Enforcement
Transport Officer
Juvenile
Corrections
Judicial Marshal
Capitol Police Officer
Corrections Worker
Forest Ranger
Probation Officer
Shellfish Warden
Harbor Master
YES
NO
Has this employee had basic training for full-time law enforcement or corrections OUT OF STATE?
Is a Waiver for either BLETP or BCOR being sought?
YES
NO
If the agency is requesting a waiver of the basic law enforcement or corrections school for this individual, please forward the appropriate
Waiver Application Packet to the Maine Criminal Justice Academy. (Available on our web site )
********************************************************************************************************************
TERMINATION DATE: ____/____/____
EMPLOYMENT LEVEL:
Full Time Law Enforcement
Part Time Law Enforcement
Transport Officer
Juvenile
Corrections
Judicial Marshal
Capitol Police Officer
Corrections Worker
Forest Ranger
Probation Officer
Shellfish Warden
Harbor Master
If termination, please indicate type
Type of Termination (Please Circle)
Resigned Discharged Retired Deceased Other_____________________________
Comments: ________________________________________________________________________________________________________
This form MUST be signed by the Department Head and submitted to the MCJA***
********************
***************
Name (please print): ___________________________________________
Title
____________________________________
Signature: ___________________________________________________
Date
____________________________________
Agency Address: ____________________________________________________________________________________________________
OFFICE LOCATED AT: 15 OAK GROVE ROAD, VASSALBORO, MAINE 04989
(207) 877-8000 (Voice)
(207) 877-8027 (Fax)
711(TTY)
Revised: 08/26/2013
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