IDLE AFFIDAVIT OF APPLICANT Florida Department of Law Enforcement Incorporated by Reference in Rule F.A.C. OJ STC 68 Please type or It and use capth and small letters for names. titles. and addresses Last Four Digits of Applicant's Social Security Number: Applicant's Legal Name: I REG 0 Last I First! Ml Employing agency: ,3 0 DD BLED HER-I FF 5 Oppl CJ: Use this form to verify your compliance with the employment requirements of Section 943.13. F.S. I fully understand that to qualify for employment as a law enforcement. correctional. or sensational probation of?cer. I shall comply with the following provisions of Section 943.13. F.S.: - Be at least 19 years of age. ?13 for correctional onicars pursuant to s. 943.131 I. shall not be eligible for employment or appointment as an of?cer. notwithstanding suspension . Be a citizen of the United States of a sentence or wittrholding of adjudication. 0 Be a high school graduate or equivalent. Have been by the employing agency. - Have passed a physical examination by a licensed medical specialist approved in Rule . Not have been convicted of any felony or of a misdemeanor involving penny or false 1132? 002(1)(d) A statement Any person who. after July 1. 1931, pleads guilty or nolo contendere found guilty of a felony or of a misdemeanor involving perjury or a false statement . Be of good moral character. Have not received a dishonorable disdiarge from the US. Military. False NA In addition. I attest to the following statements: Each statement shall be checked ?litre? "False" or 1. I completed my emptoymentapplioalion and it is true and cousin. and all other information I fumished in conjunction with my application is true and correct I provided documentation of proof of my quali?cations to the above listed employing agency. I meet the quali?cations as speci?ed above. I had a criminal record sealed or expunged. I am under investigation by a local. state, or federal agency or entity for criminal. civil. or administrative wrongdoing to the best of my knowledge and belief. I separated or resigned from a previous criminaljustice employment while under investigation. riser-new!? lam currently sewing in good standing in the US. Military. 8. I previously sewed in the US. Military. 9. I received a dishonorable discharge from my previous U.S. Military service. 10. I am currently certi?ed as a Florida criminal justice of?cer in the fattening steals]: Please check the appropriate berries]. a 12m mu Enforcement El Correctional Correctional Probation Cl 11. I authorize the employing agency listed above to apply for my certi?cation. Please check the appropriate box(es). a Law Enforcement Correctional El Correctional Probation NOTICE: This dooimentshell constitute as an of?cial statement within the purview of Section 33?.06. F.S.. and to subject to veri?cation by the employing agency and the Criminal Justice Standards and Training Commission. Any intentional omission when submitting this application orfalse execution of this attidavit shall constitute a misdemeanor of the second degree and disqgali? the of?cer for employment as an of?cer. PLEASE READ CAREFULLY BEFORE SIGNING. You must late the remainder of this af?davit in the presence of a notary public. Upon wibiessing your signing of this af?davit, a notary public shall co tary block by entering the evil is signed. I hereby certify that to the best of my united and beliefI the lnfon'natlon that I've entered on this form is true. 19. 7 ZED Applicanoe?su?feue 4 onto Signed 14. OATH Pursuant to Section Florida Statutes STATEOF lift; summer: 8 KDUJA fa) Sworn to (or af?rmed) and subscribed before me this 7 can "In mortally .wem Too 3; 5(it out on {k i Signatdr'e of Notary Public - State of?FIorida - to? TAMARA N.CLIFFORD I . A Print. Type. or stamp Co stoned name of Notary Public - - LWF by wuaar 3.5 Expires June 11. 2021 Personally Known 0R Produced Identification i $13533?" Bonded Thru Troy Fain Insurance 800-385-1019 ,u Type of Identi?cation Produced Private Correctional facilities must submit original and shall fomrd the completed af?davit stapled to the Registration of Employment, Af?davit of Compliance Form to FDLE, Criminal Justice Professionalism Program, Post Of?ce Box 1489, Tallahassee, Florida 32302-1489. Attention Records Section Created 1I1I1992 Original - Agency Copy FDLE 1 off Commission-Approved Revisions: 8I10l17 Form Effective Date: 8l2018