Affidavit For Reporting Annual Individual Officer Addresses Form

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Council on Law Enforcement Education and Training
Affidavit for Reporting Annual Individual Officer Addresses
Organization Name:
______________________________________________________________________
Organization Address:
______________________________________________________________________
City, State, ZIP:
_______________________________________________________________________
Organization Phone: _______________________________ Fax:____________________________________
I, _________________________________, Organization Director/Administrator for the above organization, do hereby
designate the individual listed below as the authorized individual appointed to submit individual officers’ home address
and phone number records to CLEET pursuant to 70 O.S., § 3311 (I) which requires that every law enforcement
agency employing police or peace officers in this state shall submit to CLEET on or before October 1 of each
calendar year a complete list of all commissioned employees with a current mailing address and phone number for
each such employee.
I understand that it is my responsibility to immediately notify CLEET should this designated contact leave the
organization and/or should the designated contact be changed. In the event I believe personal individual information or
the integrity of the system has been compromised, I agree to immediately notify CLEET and conduct reasonable
measures to correct any inaccurate information. I also understand that CLEET assumes no liability should personal
information obtained from the database be used in a negligent, malicious, or illegal manner. I understand and agree that
this organization is responsible for maintaining confidentiality of the information provided to CLEET. I agree to the
statutory provisions set forth in 70 O.S. 3311 et seq. regarding the submission of official records and acknowledge that
violating these provisions could result in criminal prosecution. I agree to maintain hard copy records of all information
submitted to CLEET. Failure to abide by the terms set forth in this agreement may result in revocation.
Designated Contact Name: ____________________________________________________________
Contact Direct Phone Number: ____________________________________FAX:_______________________
Contact E-Mail Address: _____________________________________________________________________
_________________________________________________________________________________________
Signature of Organization Director/Administrator
Title
Date
_________________________________________________________________________________________
Signature of Designated Contact (If different from Organization Administrator) Title
Date
Subscribed and sworn before me this ________ day of ______________________________, 2____________.
Signature of Notary Public:____________________________________________________________________
Commission #_________________________ My Commission expires: ________________________________

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