Georgia Peace Officer Standards And Training Council Change Of Status Form
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GEORGIA PEACE OFFICER STANDARDS AND TRAINING COUNCIL
CHANGE OF STATUS FORM
SECTION A MUST BE COMPLETED
Last Name
First Name
MI
SSN
DOB
Race
Sex
Female
White (not Hispanic or Latino)
Agency Name
Agency ID #
SECTION B MUST BE COMPLETED
Type of Change: check one box and complete the corresponding sections below.
New Hire
Promotion
Rank Change
(COMPLETE SECTIONS C AND F)
Separation (COMPLETE SECTIONS D AND F)
Name Change
Education Change
(COMPLETE SECTIONS E AND F)
Deceased
(COMPLETE SECTIONS C AND F)
SECTION C
Date:
Rank/Position
SECTION D
Date:
Type of Separation:
Voluntary Resignation
Career Retirement
Layoff
Resignation in Lieu of Dismissal
Dismissal
If resignation in lieu of dismissal,
Resignation While Under Investigation
dismissal, suspension, or demotion is
Medical Disability Retirement
Medical Disability
checked, reason for disciplinary action
Suspension: Number of Days Suspended:
must be indicated below.
Demotion
From:
To:
(indicate ranks above)
Reason for Disciplinary Action:
Officer’s Last Known Address:
SECTION E
Legal Name Change To:
Note: Legal document of change must be attached.
Education Change To:
Note: Copy of degree or transcript showing degree conferred must be attached.
SECTION F
Authorizing Signature
Date
Telephone Number
Email: _______________________
POST Form C-11 - 12/2007
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