BASIC LAW ENFORCEMENT ACADEMY REQUIREMENT CHECK LIST Please contact the Director where you intend to apply PRIOR to starting this process.

Cathy Torres – Director, 305-809-3250

Michael Crespo – Coordinator, 305-809-3231

Required Testing □ Criminal Justice Basic Abilities Test (CJBAT) ($45) To schedule test: Call 305-809-3185 Attach test results to application. (Valid FBAT scores also accepted)

Documents to be submitted to FKCC Key West Admissions Office □ FKCC Application for Admission ($30) Apply & Pay online at www.fkcc.edu . Under degree area, check the box for PSAV major enter code 621 for Law Enforcement or 640 for Crossover Corrections to Law Enforcement). Provide a copy of the completed signature page and/or other printable documents required with the application.

□ Copy of High School Diploma or GED Certificate AND Sealed Official Transcript

□ College Transcript (If attended, must be Sealed/Official transcripts) KEY WEST mailing address: FKCC, Admissions Office, 5901 College Road, Key West, FL 33040

Documents to be submitted to Institute for Public Safety □ IPS Academy Application Fee $30 (non-refundable – money order payable to FKCC/IPS attached to application)

□ Application for Admission to Institute for Public Safety (Notarized)

□ Firearms Affidavit (Notarized)

□ Physical Fitness Assessment (CJSTC Form 75, Last three pages of application)

□ Copy of Military Discharge (If applicable, Form DD 214)

□ Fingerprints ($46.75, cash only) Must be done at Monroe County Sheriff’s Office in Key West,

Marathon, or Tavernier. Use FKCC Law Enforcement Training Academy ORI# FL922240Z.

□ Driving Record (7-year Driving History) (See page 7 on how to request a copy)

□ One RECENT 2” x 2” full-color, head and shoulders passport photo (For background purposes only)

The following are required by IPS and may be required by the Admissions Office as well, please check with Admissions Office

□ Copy of Proof of Citizenship (Birth Certificate or Certificate of Naturalization)

□ Copy of Social Security Card

□ Copy of valid Driver’s License

□ Completed Financial Aid Form: FAFSA (Apply Online at www.fafsa.gov and print & attach confirmation page.)

APPLICATION FOR ADMISSION TO THE

INSTITUTE FOR PUBLIC SAFETY

Effective Date: August 14, 2017

Select Type Academy Select Center Select Type Law Enforcement Middle Keys Center Part Time Corrections Upper Keys Center Full Time/Day Time

Cross-over to Law Enforcement Key West

Cross-over to Corrections

Florida Keys Community College Institute for Public Safety

Key West Campus Upper Keys Campus 5901 College Road 89901 US Highway 1 Key West, FL 33040 Tavernier, FL 33070 Office: (305) 809-3250 Office: (305) 852-8007

Website: http://www.fkcc.edu/academics/criminal-justice.da

Applicant Name: __________________________________________________________ Date:___________________ LAST NAME FIRST NAME M.I. Primary phone number: ( _______) _______________ Email Address: ______________________________________

QUALIFICATIONS

In order to comply with the provisions of Section 943.13, Florida Statutes, the following qualifications are required for the position of law enforcement officer:

• You must be at least 19 years of age,

• You must be a citizen of the United States,

• You must be a high school graduate or equivalent,

• You must not have been convicted of any felony, or misdemeanor involving perjury or false statement, not have received a dishonorable or undesirable discharge from any of the Armed Forces of the United States. Any person who, after July 1, 1981, pleads guilty or nolo contendere to or is found guilty of a felony or of a misdemeanor involving perjury or false statement shall not be eligible for employment or appointment as an officer, notwithstanding suspension of sentence or withholding of adjudication. Notwithstanding this subsection, any person who has pled nolo contendere to a misdemeanor involving a false statement, prior to December 1, 1985, and has had such record sealed or expunged shall not be deemed ineligible for employment or appointment as an officer.

• Agree to be fingerprinted by the training school, selection center or authorized agency,

• Pass a physical examination by a licensed physician,

• Be of good moral character,

• Successful completion of a background investigation,

• Complete basic recruit training,

• Complete Affidavit of Applicant Form (CJSTC-68),

• Comply with continuing training or education requirements,

• Pass a Criminal Justice Standards and Training Commission (CJSTC) approved basic skill examination and assessment instrument, based on a job task analysis, and

• Pass the State Licensure exam.

In addition, Federal Law prohibits any individual who has been convicted of a domestic violence charge (felony or misdemeanor) from carrying a firearm. The law prohibits an individual with such a conviction from becoming a law enforcement officer.

ACADEMY FINANCIAL AID AND REFUND DISCLOSURE FORM

All FKCC Academy recruits must register with Financial Aid, regardless of their method of payment. The FAFSA application

may be completed online at www.fafsa.gov

As an applicant for a recruit program at Florida Keys Community College, Institute for Public Safety Academy, you are applying for a

program of study made up of several individual courses offered to the cohort of students that begin the program together. Each of those

courses must be successfully completed in order to continue in the program and the program in its entirety must be successfully

completed in order to be eligible to take the State Officer Certification Exam prior to employment in Florida as law enforcement,

corrections, or correctional probation officer.

No students may be added to the program by enrolling after the program begins. Regardless of whether the course was taken or not,

there will be NO refunds made after the first five (5) days of the start of an Academy.

If you are a student who receives Title IV student financial aid (Federal Pell Grants, Federal SEOG, Federal Stafford Loans or PLUS

Loans) and you withdraw, are dismissed, or your classes are canceled for any reason, your financial aid will be reviewed by the College

under the Federal Return to Title IV policy, as required by the Federal Government.

Students who withdraw or are dismissed and who receive Title IV Federal financial aid may owe the Federal Government, TCC, or

both, money based on the determination of the Federal review. These funds would be in addition to any tuition you may owe.

If you have any questions about your potential financial liability, you are directed to contact the College’s Financial Aid Office for

assistance before enrolling in this program. Your signature below acknowledges you have read and understand your financial

obligations as described above.

_________________ __________________________________________________ Date Applicant Signature

INFORMATION RELEASE FORM

NAME OF APPLICANT: _________________________________________________________ DATE OF BIRTH: _________________________________________________________ SOCIAL SECURITY NUMBER: _______________ - _______________ - _______________ ADDRESS: _________________________________________________________ PHONE #: ( _____________ ) _______________ - ________________________ E-MAIL ADDRESS: _________________________________________________________

To Whom It May Concern: I am an applicant for admission to the Florida Keys Community College, Institute for Public Safety, and Law Enforcement Academy. In order for the FKCC Institute for Public Safety to conduct a comprehensive investigation prior to my admission, it may be necessary for certain information that might otherwise be confidential, be released to them. Further, I hereby acknowledge that if I am accepted for admission, it may also become necessary for the Institute to conduct an investigation of me during my Academy class. This release authorizes disclosure of records including, but not limited to, education records, attendance records, achievement records, medical records, employment records, personal history, performance results, background investigations, polygraph examination results, any and all internal affair investigations and disciplinary records, and credit records to representatives of the Institute at any time prior to the scheduled graduation date of my class from the Institute. By copy of this form, I hereby authorize the release (including duplication of records) to representatives of the Institute for Public Safety and any and all records concerning me you may hold. I HEREBY, release you, as the custodian of such records, and any school, college, university, or other educational institution, hospital or other repository of medical records, credit bureau, lending institution, consumer reporting agency, or retail business establishment including collectively, from any and all liability for damage of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information, or any attempt to comply with it. Should there be any questions as to the validity of the release, you may contact me as indicated above. _________________ __________________________________________________ Date Applicant Signature SIGNATURE TO BE WITNESSED BY AN FKCC – IPS STAFF MEMBER _________________ __________________________________________________ Date IPS Staff Signature

FLORIDA KEYS COMMUNITY COLLEGE

INSTITUTE FOR PUBLIC SAFETY

APPLICATION INSTRUCTIONS DIRECTIONS: Please read these instructions very carefully. The application must be completed exactly according to directions. Your ability to complete the enclosed document as required will be evaluated and used as part of the Academy selection process.

Requirement Check List is provided as a guideline in order of importance. Ensure copies of all applicable documents are attached. If a document is not applicable to your admission application, mark the checklist with N/A (not applicable).

(Example: if you have not attended college, write N/A on the blank line in item #4.) College transcripts must be sent directly from your previous college to the Institute for Public Safety – copies will not be recognized as official.

• Application of Admission, Florida Keys Community College. For quick processing, please

complete and pay ONLINE at www.fkcc.edu and click on the “APPLY NOW” button on the top right-hand corner. Otherwise, you must submit a complete application along with a non-refundable $30.00 application fee and return to the Key West Admissions Office. Each new applicant is charged this fee. This is a one-time application fee and covers all subsequent enrollments. If you have previously enrolled in any course at Florida Keys Community College, this application fee is not required. IMPORTANT - Under the degree area - check the box for PSAV major and enter the correct code)

• Application to Institute for Public Safety must be completed as stated in the directions. A non-

refundable $30.00 application fee payable to FKCC/IPS in the form of a money order is to be attached to the IPS Academy Application. Any omission, falsification, misstatement or misrepresentation of any portion of this application will be the basis for disqualification or dismissal from the Academy. Completion of an Application to the Institute for Public Safety does not guarantee acceptance into the Academy.

• The Physical Fitness Assessment (CJSTC Form 75B) is required for all students attending Basic

Recruit Training. This form must be completed by the Applicant and an Examining Physician. Physical Fitness Condition Program is attached.

• Criminal History Background Check is required on all applicants entering a basic recruit-training

program. This is done using fingerprinting to conduct a background analysis on applicants. Applicants are required to obtain their fingerprints using our Agency ORI, FL922240Z. Fingerprints may be obtained at the following Monroe County Sheriff’s Offices in Key West, Marathon, or Plantation Key.

Monday-Friday 9am-11am and 1pm-3pm. Call to verify availability.

Stock Island Detention Center 305-293-7348 Marathon Substation 305-289-2430

Roth Building, Plantation Key 305-853-3211

Please return the completed Application to: Florida Keys Community College Institute for Public Safety

Key West Campus 5901 College Road

Key West, FL 33040

DO NOT MAIL TUITION FEES WITH THIS APPLICATION

The Institute for Public Safety may require applicants to attend an Interview Board. Applicants will be notified of their selection to the Basic Law Enforcement Academy by mail.

HOW TO OBTAIN A COPY OF YOUR DRIVING RECORD

OPTION # 1: BY MAIL To obtain a copy of a driving record , please submit a written request which includes the individual’s full name, date of birth or approximate age, social security number, Florida driver license number (if available) and the address where to send the record, along with the appropriate fee ($10.00 for a 7-year record. Payable by personal check or money order to the Division of Driver Licenses) to: Bureau of Records P. O. Box 5775 Tallahassee, FL 32314-5775 If you wish to use a next day delivery carrier, please send your request to: Bureau of Records 2900 Apalachee Parkway, MS 90 Tallahassee, FL 32399-0575 OPTION # 2: IN PERSON Visit the Miami-Dade Clerk of Courts, Richard E. Gerstein Building, 1351 NW 12 Street, Room 124, Miami, FL 33125. Monday-Friday, 9:00 A.M. to 4:00 P.M. Cost is $17.00 for a 7-year record plus $1 for each additional page. OPTION # 3: PRIVATE VENDOR Visit the following website: http://www.flhsmv.gov/data/internet2.html

INSTITUTE FOR PUBLIC SAFETY FLORIDA KEYS COMMUNITY COLLEGE

INSTRUCTIONS: Print legibly, using a ballpoint pen. DO NOT TYPE. Please ensure that all questions are answered completely, accurately, and truthfully. If any item does not pertain to you, please answer “N/A” (not applicable). Keep in mind that all information will be checked and verified. Please note that any misstatements, falsifications, or omissions may delay entrance to Institute for Public Safety. LAST NAME FIRST NAME MIDDLE NAME MAIDEN STREET ADDRESS (NOT P.O. BOX) MAILING ADDRESS IF DIFFERENT THAN ABOVE CITY COUNTY STATE ZIP CODE _____________________________ SEX: MALE_______ FEMALE_________ HOME TELEPHONE _____________________________ 9000 ____ ____ ____ ____ ____ CELLULAR PHONE FKCC STUDENT NUMBER _____________________________ __________________________________ SOCIAL SECURITY NUMBER DRIVER LICENSE NUMBER/STATE

__________________________ ________________________________ DATE OF BIRTH (MM/DD/YYYY) PLACE OF BIRTH

PHOTO MUST BE TAKEN NO MORE THAN SIX MONTHS PRIOR TO SUBMISSION

PHOTO

1. List any names you may have used. Please include former names, aliases, and/or nicknames. 2. Ethnic Origin (optional) _____ White ______ Asian or Pacific Islander ______ Hispanic _____ Black, Non Hispanic ______ American Indian/ Alaskan Native ______ Other 3. Citizenship: U.S. Citizen ______ YES ______ NO Naturalized Certificate No. ______________________ Country of Origin _________________

Date and Location_____________________________________________________________________ 4. Height________ Weight________ Eye Color________ Hair Color________ T-shirt Size(Uniform purposes)________ 5. With whom do you reside? ____________________________________________________________ 6. Marital Status: _______ Single _______ Married _______ Engaged _______ Separated _______ Divorced 7. If married, are you living with your spouse? _______ YES ________ NO 8. Information concerning marriages: (List all marriages)

Date Married Where Performed

(City & State) Spouse’s Complete Name

(Include maiden name) Date of Birth Social Security No.

9. Name and address of spouse(s) if divorced or separated. (Attach copies of Divorce Decree)

Name Address Date of order or decree where

issued (Court & State) Phone Number &

Social Security No.

10. RESIDENCES:

List all residences for the past TEN years, beginning with your present address. List the name, address and phone number of present and prior landlords, if applicable. (If needed, attach additional sheets using the same format.)

Month/ Year & Own/ Rent

Your address (Include street, city county, state & zip code)

Landlord’s Name (Include street, city county, state & zip code)

From: To: ____ Own ____ Rent

From: To: ____ Own ____ Rent

From: To: ____ Own ____ Rent

From: To: ____ Own ____ Rent

From: To: ____ Own ____ Rent

From: To: ____ Own ____ Rent

11. EDUCATION:

A. List all elementary, junior high and high schools attended:

Full Name Complete Address Dates

Attended Years

Completed Graduated To:

From:

____ Yes ____ No

To: From:

____ Yes ____ No

To: From:

____ Yes ____ No

To: From:

____ Yes ____ No

B. Higher education. List information below for all colleges or universities attended:

Name & Location of College or University Dates Attended Credit Hours

Degree Received and Year it was Received

To: From:

To: From:

To: From:

To: From:

C. Other schools or training (trade, vocational, business, specialized or military). For each school or training, give the name and location of school, dates attended, subjects studied, certificate and any other pertinent data.

Dates Attended Name of School & Location (Complete Address) Courses Studied Certificate To: From:

____ Yes

____ No

To: From:

____ Yes

____ No

D. If “YES”, provide details on the bottom of this page or on a separate piece of paper. YES____ NO____ Were you ever suspended or expelled from school? YES____ NO____ Were you ever subject to disciplinary actions while in school? YES____ NO____ Were you ever held back a school year? YES____ NO____ Did you ever receive any awards or honors in school? YES____ NO____ Have you any specialized training or courses? YES____ NO____ Do you have any specialized skills? YES____ NO____ Are you currently enrolled in school? YES____ NO____ Do you have any computer experience? E. Have you applied to any other academies? _____ Yes _____ No If “yes”, list date(s) and academy: F. Have you attended any other academies? _____ Yes _____ No If “yes”, list date(s) and academy: G. Foreign Language: Do you speak, read, write or understand any foreign languages? _____ Yes _____ No If “yes”, provide the following information:

Language Reading Speaking Understanding Writing

______ Fair _______ Good _______ Excellent

______ Fair _______ Good _______ Excellent

______ Fair _______ Good _______ Excellent

______ Fair _______ Good _______ Excellent

______ Fair _______ Good _______ Excellent

______ Fair _______ Good _______ Excellent

______ Fair _______ Good _______ Excellent

______ Fair _______ Good _______ Excellent

12. MILITARY If you answer “yes” to any of the following questions, give details on the bottom of this page. In this section, Armed Forces is defined as any military, paramilitary or Coast Guard organization of any nation, including R.O.T.C., or any Reserve component thereof, or any National Guard component.

Yes No

Are you registered with the Selective Service System? If yes, give date and location registered and current selective service classification number. DATE: NUMBER:

Have you received information from the Selective Service System indicating that you may be inducted into the Armed Forces in the near future?

Have you ever served in a military or naval organization of the United States, including R.O.T.C.?

Have you ever served in the Armed Forces of another country?

Are you now or have you even been a member of the National Guard of any state?

Were you ever tired, punished, reprimanded or reduced in rank for any infraction, rule or regulation while in the Armed Forces?

Has your separation or discharge even been changed?

Did you ever receive any medals, awards or decorations?

Are you on active duty at this time?

Did you ever file a disability claim with the Veteran’s Administration?

Have you ever asked for or received a deferment from military service?

Were you employed by the Government of a foreign nation?

What type of discharge? (Attach DD214 with separation codes) _____ Honorable _____ Dishonorable _______ General _______ Medical ______ Honorable Conditions ______ Other

List period or periods of active or reserve military service

Period 1 Period 2 Period 3 Period 4 Military Branch

Military Branch

Military Branch

Military Branch

Highest Rank

Highest Rank Highest Rank Highest Rank

Organizational Unit

Organizational Unit Organizational Unit

Organizational Unit

From To From To From To From To

13. EMPLOYMENT (If you answer yes to any of the below listed questions, give details on the bottom of this

page.) YES NO

1. Do you object to your present employer being contacted?

2. Were you ever discharged, terminated, fired or forced to resign from a job?

3. Have you ever been suspended by an employer?

4. Have you ever had your pay garnished by an employer?

5. Has an employer ever taken disciplinary action against you?

6. Do you object to wearing a uniform?

7. Do you object to working nights, weekends or holidays?

8. Do you object to working shift work?

9. Have you ever had experience with shift work?

10. Do you require any special equipment or accommodation to perform law enforcement and/or correctional officers’ job?

Have you ever received unemployment insurance or other Federal, State or Local benefits or assistance, not including Worker’s Compensation?

Type of Assistance Local Office Address For how long?

LIST ANY AND ALL JOBS THAT YOU HAVE EVER HAD, STARTING WITH PRESENT JOB. #1 From: To:

Name of Employer Reason for Leaving

Part Time ________ Full Time ________

Street Address Name of Supervisor

Position Title: City, State & Zip Code Duties

Salary Starting: Ending:

Telephone #

Type of Business Name & Address of Co-Worker

#2 From: To:

Name of Employer Reason for Leaving

Part Time ________ Full Time ________

Street Address Name of Supervisor

Position Title: City, State & Zip Code Duties

Salary Starting: Ending:

Telephone #

Type of Business Name & Address of Co-Worker

#3 From: To:

Name of Employer Reason for Leaving

Part Time ________ Full Time ________

Street Address Name of Supervisor

Position Title: City, State & Zip Code Duties

Salary Starting: Ending:

Telephone #

Type of Business Name & Address of Co-Worker

#4 From: To:

Name of Employer Reason for Leaving

Part Time ________ Full Time ________

Street Address Name of Supervisor

Position Title: City, State & Zip Code Duties

Salary Starting: Ending:

Telephone #

Type of Business Name & Address of Co-Worker

#5 From: To:

Name of Employer Reason for Leaving

Part Time ________ Full Time ________

Street Address Name of Supervisor

Position Title: City, State & Zip Code Duties

Salary Starting: Ending:

Telephone #

Type of Business Name & Address of Co-Worker

#6 From: To:

Name of Employer Reason for Leaving

Part Time ________ Full Time ________

Street Address Name of Supervisor

Position Title: City, State & Zip Code Duties

Salary Starting: Ending:

Telephone #

Type of Business Name & Address of Co-Worker

If needed, attach additional sheets using the same format. 14. VEHICLE OPERATOR’S LICENSE: (Driver’s, Chauffeur’s, etc.) Attach Driving Record The purpose of the following questions is to determine general driving ability. If you answer “Yes” to any of the below questions, give details on the back of this page. Yes No

1. Have you even been refused a driver’s license by any state?

2. Has your driver’s license ever been revoked or suspended?

3. Was your driver’s license ever restored?

4. Have you ever received a traffic citation?

5. Have you ever been involved in a motor vehicle accident?

6. Have you ever had an accident while operating an emergency vehicle?

7. Do you have any traffic citations which have you failed to pay?

8. Do you have any parking tickets you failed to pay?

9. Have you ever had automobile insurance withdrawn or revoked, or have you ever been refused auto insurance?

10. Have you ever been charged with driving a motor vehicle while under the influence of alcoholic beverages, chemical substances or controlled substances?

11. Have you ever refused to submit to a breath, blood or urine test to determine the influence of alcoholic beverages, chemical substances or controlled substances?

12. Have you ever been licensed to drive in another state?

If “yes” to any accident question, give details for each accident whether collision, non-collision or hit and run. Date: Location: Cause of accident (ran red light, careless

driving, etc.)

Police Investigation: ____ yes ____ no ________________________________ Injury ________ Non-injury _________

Who was charged with accident and court disposition?

Date: Location: Cause of accident (ran red light, careless

driving, etc.)

Police Investigation: ____ yes ____ no ________________________________ Injury ________ Non-injury _________

Who was charged with accident and court disposition?

List all traffic citations you have received: (including parking tickets)

Location (Street, City & State) Approximate Date Nature of Violation Penalty or

Disposition

List all vehicles that you currently own or operate:

Year Make Model Color Tag # Own ____ yes

____ no

____ yes ____ no

____ yes ____ no

Do you presently have automobile liability insurance? ___________ Yes _________ No If “No”, give details: _______________________________________________________________________________ 15. ARRESTS, DETENTION AND LITIGATIONS: EXCEPT TRAFFIC VIOLATIONS If you answer “yes” to any of the below questions, you must submit details. YES NO 1. Have you ever been arrested or charged or received a notice or summons to appear for any criminal violation or detained by ANY law enforcement agency? (Provide court copies for any arrest(s) and/or arrest(s) where records were expunged, including juvenile records.)

2. Have law enforcement officers ever been called to your home? 3. Has anyone ever called the police about you or one of your family members? 4. Have you ever been the subject of a criminal investigation? 5. Have you ever been convicted of a crime? 6. Have you ever been required to pay a fine (other than traffic)? 7. Have you ever been fingerprinted by a law enforcement agency for criminal reasons? 8. Have you ever been questioned as a suspect for any crime? 9. Have you ever been advised of your Miranda rights? 10. Have you ever been placed on probation? 11. Have you ever had any records sealed or expunged? 12. Have you or any members of your immediate family ever been a victim of a crime? 13. Have you or your spouse ever sued anyone (civil court plaintiff)? 14. Have you or your spouse ever been sued by anyone (civil court defendant)? If any of the above questions resulted in a court case, please provide copies of the court case disposition. 16. POLYGRAPH EXAMINATION/ VOICE STRESS ANALYSIS/ FINGERPRINTS Have you ever had a polygraph examination? _______ Yes ______ No (If yes, please give details below.)

Date Examiner’s Name Location Purpose

Have you ever had a voice stress analysis? _______ Yes ______ No (If yes, please give details below.)

Date Examiner’s Name Location Purpose

Have you ever been fingerprinted? _______ Yes ______ No (If yes, please give details below.)

Date Examiner’s Name Location Purpose

17. CONTROLLED SUBSTANCE USE Check all that apply for each drug. If “YES” to any of the following questions indicate the approximate number of times in each appropriate column(s), provide the date last used, and give details below.

• Have you ever used, sold, transported, delivered or possessed any of the following substances other than as allowed by the law?

Used Sold Transported Delivered Possessed Yes No Date Last Used Marijuana Hallucinogenic Drug Amphetamines Cocaine Ecstasy Barbiturates Tranquilizers Heroin Any other illegal drug Misused a prescription drug Obtained a prescription

through fraud

Used someone else’s prescription drug

Steroids 18. CHARACTER REFERENCES (Do not include relatives, former employers, supervisors or persons living outside the United States). List only character references that have definite knowledge of your qualifications for the position for which you are applying. List four (4) character references.

Name of Character Reference Years Known

Address (Street, City, State & Zip Code)

Business Phone #

Home Phone #

19. PAST AND/OR PRESENT MEMBERSHIP IN ORGANIZATIONS

Name, Address & Phone # Type (Social, Fraternal, Unions, Professional,

Academic, Etc.) Office or Position Held Membership

20. Are you acquainted with any Monroe County Employee in Law Enforcement or Corrections? Name of Officer (s) Agency Name 21. CIVIL SERVICE (List below EVERY criminal justice agency you have applied to. If none, so state.) Agency (City & State) Approx Date of

Examination Position Applied For Position on List Present Status

Are you on any agency’s eligibility list? ______ Yes _____ No If “Yes”, give details below: If you were ever placed on an eligibility list and were not hired, state why: Were you ever rejected for any criminal justice agency position? ______ Yes ______ No If “Yes”, state reasons why:

22. Are there any incidents in your life not mentioned herein which may reflect upon your suitability to enter a criminal justice training program, which requires further explanation? _____ Yes ____ No If “yes”, state reasons why:

ESSAY PORTION 23. (Please answer in your own, hand written words.) WHY DO YOU WANT TO BECOME A CRIMINAL JUSTICE OFFICER?

NOTE Criminal Justice Records ordered sealed under Section 943.058, Florida Statutes, are available from the FCIC System for inspection by a criminal justice agency for purposes of criminal justice employment. The applicant is to be advised that applicant may not lawfully deny arrests or convictions, notwithstanding adjudication being withheld or the sealing or impingement of arrests/conviction records. The applicant is being advised that a misdemeanor arrest or conviction may not necessarily disqualify applicant.

I HEREBY, SWEAR OR AFFIRM THAT THERE ARE NO MISREPRESENTATIONS OR OMISSIONS IN OR FALSIFICATIONS OF THE ABOVE STATEMENTS AND ANSWERS TO QUESTIONS. I AM AWARE THAT, SHOULD INVESTIGATION DISCLOSE SUCH MISREPRESENTATIONS, OMISSIONS, OR FALSIFICATIONS, MY APPLICATION WILL BE REJECTED; AND I WILL BE DISQUALIFIED FROM APPLYING IN THE FUTURE. IF, AFTER MY ACCEPTANCE FOR THE ACADEMY, SUBSEQUENT INVESTIGATION SHOULD DISCLOSE MISREPRESENTATIONS, OMISSIONS, OR FALSIFICATIONS, IT WILL BE CAUSE FOR IMMEDIATE DISMISSAL. I FURTHER UNDERSTAND THAT ALL TEST RESULTS INCLUDING BUT NOT LIMITED TO PSYCHOLOGICAL EVALUATION AND POLYGRAPH TEST IS FOR ACADEMY USE ONLY AND WILL NOT BE RELEASED TO MYSELF OR ANY PERSON AND/OR AGENCY OUTSIDE OF THE INSTITUTE FOR PUBLIC SAFETY AT FLORIDA KEYS COMMUNITY COLLEGE. ___________________________________________ APPLICANT SIGNATURE ___________________________________________ DATE County of ________________ SUBSCRIBED AND SWORN TO (OR AFFIRMED) BEFORE ME, THIS __________ DAY OF _____________________ A.D. 20 _____ HE/SHE IS PERSONALLY KNOWN TO ME OR HAS PRESENTED ___________________________________ AS IDENTIFICATION. ___________________________________________ NOTARY PUBLIC ___________________________________________ MY COMMISSION EXPIRES NOTARY SEAL

1. Are you under indictment or information in any court for a crime for which the judge could imprison you for more than one year? Information is a formal accusation of a crime made by a prosecuting attorney(i.e.; the State Attorney's Office, U.S. Attorney's Office).

Institute for Public Safety Florida Keys Community College

Firearms Training Affidavit

The purpose of this Firearms Training Affidavit is to determine if the applicant is eligible to possess a firearm and participate in firearms training in accordance with the Federal Firearms Law 18 U.S.C. 922, the Gun Control Act of 1967 and the Omnibus Consolidated Appropriations Act of 1997. Amendments to the Gun Control Act of 1968 make it unlawful for any person convicted of a "misdemeanor crime of domestic violence" to ship, transport, possess, or receive firearms or ammunition. The amendments also make it unlawful for any person to sell or otherwise dispose of a firearm or ammunition to any person knowing, or having reasonable cause to believe that the recipient has been convicted of such a misdemeanor. The new prohibitions apply to all persons, including law enforcement officers. To be certified by the Criminal Justice Standards and Training Commission, a recruit must demonstrate proficiency skills in criminal justice weapons. This proficiency must be demonstrated by each recruit during his/her basic training weapons course. The course requires the recruit to demonstrate proficiency in the use of a service handgun and shotgun. Under the Federal Gun Control Act, someone is prohibited from buying and possessing a firearm if (s)he (CHECK ALL THAT APPLY, IF APPLICABLE) � is either under direct indictment or has been convicted for a crime punishable by imprisonment for more than one year; � is a fugitive from justice; � is an unlawful user of or addicted to any controlled substance. � has been adjudicated as mentally defective or been committed to a mental institution; � was dishonorably discharged from the Armed Forces; � has renounced United States citizenship; � is subject to a court order restraining him/her from harassing, stalking, or threatening an intimate partner or a child; � has been convicted of domestic violence. In response, Florida Keys Community College must ask the following questions in order to comply with the requirements of the Omnibus Consolidated Appropriations Act of 1997. I understand that a person who answers "YES" to any of the questions is prohibited from purchasing and possessing a firearm. I also understand that the making of any false oral or written statement in response to the above questions is a crime punishable as a felony. I also understand that a person who answers YES" to any of the questions cannot be admitted to the Law Enforcement or Correctional Officer training programs because (s)he cannot possess a firearm which is a requirement of the program curriculum.

No _____ Yes_____ If YES, explain: ________________________________________________________________________________________________________________________________________________________________________________ 2. Have you ever been convicted in any court of a crime for which the judge could have imprisoned you for more than one year, even if the judge actually gave you a shorter sentence? No _____ Yes_____ If YES, explain: ________________________________________________________________________________________________________________________________________________________________________________ 3. Are you a fugitive from justice? No _____ Yes_____ If YES, explain: ________________________________________________________________________________________________________________________________________________________________________________ 4. Are you an unlawful user of or addicted to marijuana, any depressant, stimulant or narcotic drug, or any other controlled substance? No _____ Yes_____ If YES, explain: ________________________________________________________________________________________________________________________________________________________________________________ 5. Have you ever been adjudicated mentally defective or been committed to a mental institution? No _____ Yes_____ If YES, explain: ________________________________________________________________________________________________________________________________________________________________________________ 6. Have you been discharged from the Armed Forces under less than honorable conditions? No _____ Yes_____ If YES, explain: ________________________________________________________________________________________________________________________________________________________________________________ 7. Are you an alien illegally in the United States? No _____ Yes_____ If YES, explain: ________________________________________________________________________________________________________________________________________________________________________________ 8. Have you ever renounced your United States Citizenship? No _____ Yes_____ If YES, explain: ________________________________________________________________________________________________________________________________________________________________________________ 9. Are you subject to a court order restraining you from harassing, stalking, or threatening an intimate partner or child of such a partner? An intimate partner is defined as the spouse of the person, a former spouse of the person, an individual who is a parent of a child of the person, or an individual who cohabitates or has cohabitated with the person?

No _____ Yes_____ If YES, explain: ________________________________________________________________________________________________________________________________________________________________________________ 10. Have you been convicted in any court of a misdemeanor crime of domestic violence? This includes any misdemeanor conviction involving the use or attempted use of physical force or threatened use of a deadly weapon committed by a current or former spouse, parent, guardian of the victim, by a person with whom the victim shares a child in common, by a person who is cohabiting with or has cohabited with the victim as a spouse, parent, or guardian of the victim or by a person similarly situated as a spouse, parent or guardian of the victim. This includes all misdemeanors that involve the use of or attempted use of physical force (e.g., simple assault, assault, assault and battery), of the offense is committed by one of the defined parties. A person is not considered to have been "convicted for purposes of the Federal Law if the conviction has been expunged or set aside or is an offense for which the person has been pardoned or has civil rights restored, unless, the pardon, expungement or restoration of civil rights expressly provides that the person may not ship, transport, possess/receive firearms. No _____ Yes_____ If YES, explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I certify that the above answers are true and correct. I understand that a person who answers “YES” to any of the questions is prohibited from purchasing and possessing a firearm. I also understand that the making of any false (oral or written) statement in response to the above

questions are a crime punishable as a felony. ________________________________ __________________________ Signature of the Applicant Date of Signature County of _______________ SUBSCRIBED AND SWORN TO (OR AFFIRMED) BEFORE ME, THIS __________ DAY OF _____________________ A.D. 20 _____ HE/SHE IS PERSONALLY KNOWN TO ME OR HAS PRESENTED ___________________________________ AS IDENTIFICATION. ___________________________________________ NOTARY PUBLIC ___________________________________________ MY COMMISSION EXPIRES NOTARY SEAL

INSTRUCTIONS FOR COMPLETING FORM CJSTC-75B

Florida Department of Law Enforcement

PHYSICIAN’S ASSESSMENT Incorporated by Reference in Rules

11B-27.002(1)(d) and 11B-35.001(10)(d)14., F.A.C.

1. Applicant’s Name: Last First MI

2. Last Four Digits of the Applicant’s Social Security Number:

3. Hiring Agency:

4. Training School:

5. The Applicant Is Requesting Employment and/or Admission Into a Basic Recruit Training Program in One of the Following Disciplines: Law Enforcement Correctional Correctional Probation

Note: For employment, a position description that describes the job duties the applicant will perform must be provided. For training, the physical fitness conditioning program developed by the training center must be provided.

6. Student Participation in Basic Recruit Training Program. A student enrolled in a basic recruit training program (BRTP) is required to participate in the following activities: A. Defensive tactics and firearms high-liability training is a component of the curriculum mandated by the Criminal Justice Standards and Training Commission. Firearms

training requires firing a handgun and long gun creating exposure to lead. Defensive tactics training requires sustained physical exertion and chemical agent contamination to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzalmalononitrile (CS).

B. Physical Fitness Conditioning and Physical Fitness Testing: A BRTP student shall participate in physical fitness conditioning and a fitness test and includes the following measures:

• Vertical Jump • One Minute Sit Ups • 300 Meter Run • Maximum Push Ups • 1.5 Mile Run/Walk C. The training center director has attached the training school’s physical fitness conditioning program: Yes No

**********TO BE COMPLETED BY THE STUDENT********** 7. Medical Conditions Regarding OC/CS Contamination. A BRTP student should be aware of the following personal considerations that may restrict participation in the chemical

agent contamination of the BRTP and could possibly be aggravated to a severe degree during the contamination: Recent eye surgery, heart problems, panic disorder or stress, respiratory disorder, emphysema (loss of elasticity/thinning of lung tissues), bronchial asthma, x-ray evidence of pneumoconiosis (black lung), evidence of reduced pulmonary (lung) function, chronic obstructive pulmonary disease, coronary (heart) artery disease, cerebral (brain) blood vessel disease, severe or progressive hypertension (high blood pressure), epilepsy, generalized seizures, pernicious anemia (severe reduction in red blood cells), diabetes (any form), pnueumomediastinum gap (air in the sac surrounding lungs), history of skin allergies, or any condition for which the student is presently taking medication.

8. BRTP Student Certification. I certify that I have reviewed the above information and I do or do not have any medical restrictions that would prevent me from participating in the basic recruit training program activities outlined in item numbers 6A and 6B above.

9. Student’s Printed Name: 10. Student’s Signature: Date 11. To the Examining Physician:

The examination of this applicant is for employment or training as an officer, and shall include a complete physical examination at a level of specificity sufficient to determine whether there is any medical or physiological reason that would prevent the applicant from performing the essential functions for employment or training as an officer for the discipline indicated in number 5 above. Disabilities, impairment, or limitations identified by the examination, which would prevent the applicant from performing the essential functions for the officer position, should be reported to the employing agency.

12. Physician’s Attestation: I hereby attest that I have examined the above named applicant and find him/her CAPABLE of participating in basic recruit training and/or performing the essential functions of the law enforcement, correctional, or correctional probation officer job for which the applicant is seeking employment and/or training reflected in number 3 and/or 4 above. I hereby attest that I have examined the above named applicant and find him/her NOT CAPABLE of participating in basic recruit training and/or performing the essential functions of the law enforcement, correctional, or correctional probation officer job for which the applicant is seeking employment and/or training reflected in number 3 and/or 4 above.

13. Pre-existing Conditions: Sections 112.18 and 943.13, F.S., require agency knowledge of the following three pre-existing conditions. However, these outcomes do not statutorily disqualify the applicant from employment. Please respond to the following “in my professional opinion, this examination”:

13a. Did or did not reveal evidence of tuberculosis.

13b. Did or did not reveal evidence of heart disease.

13c. Did or did not reveal evidence of hypertension.

14. Physician, Certified Advanced Registered Nurse Printed Name Examination Date Practitioner, or Physician Assistant’s Signature

15. Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s License Number Licensing State

16. Physician, Certified Advanced Registered Nurse Practitioner, or Physician Assistant’s Professional Address Created 1/1/1996 Original - Agency 1 of 3 Commission-Approved Revisions: 8/4/16

Form Effective Date: 7/2017

CJSTC 75

FORM CJSTC-75

INSTRUCTIONS FOR COMPLETING FORM CJSTC-75

Use this form to document and verify the applicant’s compliance with the employment requirements of Section 943.13, F.S., and Rule 11B-27.002(1)(d), F.A.C., and/or with the Basic Recruit Training Program entrance requirements of Rule 11B-35.001(14)(b), F.A.C.

GENERAL INSTRUCTIONS

• The physical examination must be performed by a physician licensed under Chapters 458 or 459, F.S., a certified advanced registered nurse practitioner, or a physician assistant.

• This form or an equivalent form, indicating that the officer is capable of performing the essential functions of the law enforcement, correctional, or correctional probation officer duties for which the applicant is seeking employment, is required for each new employment or appointment of an officer and may shall be used in conjunction with the Patient Information form CJSTC-75A or an equivalent form, to assist the physician, certified advanced registered nurse practitioner, or physician assistant, by providing testing guidelines to examine the applicant. The physical examination shall not be completed more than one year prior to the officer’s date of employment or appointment and a CJSTC-75 form completed for one employing agency may not be used by any other employing agency. If the examination is for employment only, sections 6 – 10 are not required.

• This form, indicating that an applicant is capable of participating in a Basic Recruit Training Program (BRTP), is required if the applicant is entering a BRTP and must be completed prior to entrance into a BRTP. The completed form must be maintained in the BRTP course file.

• If an applicant is entering a Basic Recruit Training Program and gaining employment with a criminal justice agency at the same time, a single CJSTC-75 form may be completed for the employing agency and for the training center. The original CJSTC-75 form should reside at the employing agency with a copy being provided to the training center.

INSTRUCTIONS ON HOW TO COMPLETE THIS FORM 1. Applicant’s Name: Enter the applicant’s full legal name. 2. Last Four Digits of the Social Security Number: Enter the last four digits of the applicant’s social security number. 3. Hiring Agency: Enter the hiring agency’s name (if applicable). 4. Training Center: Enter the training center’s name (if applicable). 5. Request for Employment and/or Training as an officer: Place a check mark in the box for the discipline in which the applicant is being employed or completing training. 6. Student Participation in Basic Recruit Training Program Activities. Defensive Tactics (includes chemical agent contamination), Firearms, and Physical Fitness

Conditioning and Physical Fitness Testing: High-liability training in defensive tactics, firearms, and chemical agent contamination is a component of the curriculum mandated by the Criminal Justice Standards and Training Commission and participation in the activities is a requirement for successfully completing a BRTP. There is no pass or fail at this time. The test results for each of the five required tests will be recorded on the Academy Physical Fitness Standards Report, form CJSTC-67A as “I” if the student did not perform the test component or “D” if the student was dismissed from the basic recruit training program. A. Defensive Tactics and Firearms Training. Firearms training requires firing a handgun and long gun creating exposure to lead. Defensive tactics training requires

sustained physical exertion and chemical agent contamination to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzalmalononitrile (CS). B. Physical Fitness Conditioning and Physical Fitness Testing. The Physical Fitness Test includes the following measures and are defined as follows:

• Vertical Jump. This measures leg power by measuring how high a person jumps. • One Minute Sit Ups. This measures abdominal, or trunk, muscular endurance. While lying on his or her back, the student will be given one minute to do as

many bent-leg sit ups as possible. • 300 Meter Run. This measures anaerobic power, or the ability to make an intense burst of effort for a short time period or distance. This component consists of

sprinting 300 meters as fast as possible. • Maximum Push Ups. This measures the muscular endurance of the upper body. This component consists of doing as many push-ups as possible until muscular

failure. Males are required to perform the standard push-up and females have the option to perform the standard or modified push-up. • 1.5 Mile Run/Walk. This measures aerobic power or cardiovascular endurance (stamina over time). To complete this component, the student runs or walks a

distance of 1.5 miles as fast as possible. C. A physical fitness conditioning program developed by the training school shall be attached to form CJSTC-75 prior to the student’s examination by a

physician, certified advanced registered nurse practitioner, or the physician assistant. 7. Medical Conditions Regarding Chemical Agent Contamination. The student shall review the listed medical conditions and list other conditions that may restrict him or her

from participating in Chemical Agent Contamination to the chemicals oleo-resin capsicum (OC) and/or orthochlorobenzalmalononitrile (CS). 8. Basic Recruit Training Program Activities Certification. The student shall check the appropriate box to indicate if he or she does or does not have a medical condition

that would restrict participation in the BRTP activities indicated in item numbers 6A and 6B of this form. 9. Student’s Printed Name. The student shall print his or her first name, last name, and middle initial. 10. Student’s Signature and Date. The student shall provide a signature and date to verify the information provided by the student is true and correct. 11. Examining Physician: The examining physician shall examine the applicant for any medical or physiological reasons that would prevent the applicant from entry into a BRTP

or as an officer for employment purposes, pursuant to the attached job duties and/or physical conditioning program. 12. Physician’s Attestation: The physician, certified advanced registered nurse practitioner, or physician assistant shall mark the appropriate box attesting that the applicant is

capable or not capable of participating in basic recruit training and/or performing the essential functions of the law enforcement, correctional, or correctional probation officer discipline for which the officer/applicant is seeking training and/or employment.

13. Pre-existing Conditions: The physician, certified advanced registered nurse practitioner, or physician assistant shall mark the appropriate box for each pre- existing condition attesting that the examination of the applicant Did or Did Not reveal evidence of the pre-existing conditions listed. These outcomes are not disqualifying for employment.

14. Signature: The physician, certified advanced registered nurse, or physician assistant shall sign and print his or her name and enter the examination date. 15. License Number: Enter the physician, certified advanced registered nurse practitioner, or physician assistant’s license number and licensing state. 16. Professional Address: Enter the physician, certified advanced registered nurse, or physician assistant’s professional address.