Form 3 - Application For Provisional Certification - Colorado Department Of Law

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FORM
APPLICATION FOR
3
PROVISIONAL CERTIFICATION
Colorado Department of Law
December 2015
Criminal Justice Section, POST Board
th
1300 Broadway 9
Floor
Denver, CO 80203
post@state.co.us
720-508-6721 FAX 866-858-7486
_______________________________________________________________________________________________________
Last Name
First
Full Middle
_______________________________________________________________________________________________________
Home Address
City
State
Zip
_______________________________________________________________________________________________________
Mailing Address (if different from above)
City
State
Zip
Aliases:________________________________ Cell Phone: _____________________________
NOTE: All personal information
provided to POST is confidential
Email: _________________________________________________________________________
and will not be released to the
public, pursuant to
Home Telephone: ________________________
SSN: ______________________________
§ 24-72-204, C.R.S.
Date of Birth: ________________________
Sex:
M
F
1.
I am eligible for provisional certification in Colorado on the basis of my being fully certified in another state
and having worked at least one year in the past three years.
2.
My law enforcement appointments within the past three years are as follows:
___________________________________________________________________________________________________
Agency
City
State
From: _____________________
To:______________________
___________________________________________________________________________________________________
Agency
City
State
From: ______________________
To: ______________________
3.
I possess a high school diploma or its equivalent. (Attach copy of diploma or certificate.)
4.
I possess current first aid and cardiopulmonary resuscitation certification. (Attach copies showing front and back of each card.)
5.
I have submitted my fingerprints on a POST fingerprint card to the Colorado Bureau of Investigation.
6.
I have not been convicted of any felony or any misdemeanor as referenced in § 24-31-305(1.5), C.R.S. (2005).
7.
I am not under investigation or pending investigation for any felony or any misdemeanor as referenced in
§ 24-31-305(1.5), C.R.S. (2005).
8.
I have
have not served in the United States military and have have not been released or discharged under dishonorable
conditions. (Attach copy of DD-214 showing Character of Service)
9.
I am a United States citizen or legal resident and I am lawfully present in the United States pursuant to Federal Law
and §24-76.5-103, C.R.S.
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE EXAMINED THIS AFFIDAVIT AND ACCOMPANYING DOCUMENTS, AND TO THE
BEST OF MY KNOWLEDGE AND BELIEF, THEY ARE TRUE, CORRECT, AND COMPLETE. I FURTHER ACKNOWLEDGE THAT ANY FALSE
STATEMENT, MISSTATEMENT, OR INACCURACY MAY RESULT IN REVOCATION OF MY CERTIFICATION, AS WELL AS CRIMINAL PROSECUTION.
____________________________________________________________
Date: ________ - ________ - ___________
Applicant's Signature
Subscribed and sworn to before me this ___________ day of ____________________________________, ___________________
My Commission Expires: _____--_____--________
_____________________________________________________
NOTARY PUBLIC

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