Cjstc Form 71 – Fill Out and Use This PDF

Florida Department of Law Enforcement

INSTRUCTOR CERTIFICATION

APPLICATION

Incorporated by Reference in Rule 11B-20.001(2)(a), F.A.C.

CJSTC

71

6.Enter “X” in the box that indicates the instructor’s current status:

Officer

*Non-Officer or Civilian

*For non-sworn applicants the training center director, agency administrator, or designee shall ensure the applicant meets the requirements of Rule 11B-20.001(2)(b)-(c), F.A.C., regarding felony convictions.

7.Employer:

(Do not abbreviate employer name)

8.Employer Address: (Street)

City:

State:

Zip Code:

Telephone Number:

9.Instructor Applicant’s Contact Information: Office or Mobile Telephone Number: E-mail Address:

10.Enter “X” in one of the following boxes to apply for:

New

Add Subjects

Change of Affiliation

General	Law
Vehicle Operations	Speed Measurement
Firearms	Canine Team
Defensive Tactics	Breath Test
First Aid

12.The applicant agrees that he or she has not been convicted of a felony or misdemeanor involving perjury or a false statement; has not received a dishonorable discharge from any of the Armed Forces of the United States; and has not after July 1, 1981, pled guilty or nolo contendere or have been found guilty of any felony or of a misdemeanor involving perjury or a false statement, notwithstanding suspension of sentence or withholding of adjudication; and has not had a certification issued by the Criminal Justice Standards and Training Commission relinquished or revoked.

Signature

Date Signed

I hereby affirm that the above information is true and can be verified by documents on file. Training school or agency staff: Verify all requirements are met and applicable documentation is attached and apply for certification through the Commission’s ATMS or by submitting to Commission staff.

Instructor applicants applying for instructor certification shall:

1.Be affiliated with a training school or agency.

2.Possess good moral character pursuant to Rule 11B-27.0011(4), F.A.C., as applied to instructor applicants and certified instructors.

3.Not have been convicted of a felony or of a misdemeanor involving perjury or false statement, or have received a dishonorable discharge from any of the Armed Forces of the United States; and

4.After July 1, 1981, any person who has pled guilty or nolo contendere to any felony or of a misdemeanor involving perjury or a false statement is not eligible for instructor certification, notwithstanding suspension of sentence or withholding of adjudication; and

5.Notwithstanding subsections (3) and (4) of Rule 20.001(2)(c)3., F.A.C., 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 instructor certification.

6.Meet the requirements of Rule Chapter 11B-20, F.A.C.

Instructions for Completing Form CJSTC-71:

1.This form is required by the Criminal Justice Standards and Training Commission (CJSTC) to apply for instructor certification, add subject(s), or change the instructor’s affiliation.

2.Instructor applicants shall complete items 1 - 12 and submit to a Commission-certified criminal justice training school or the instructor applicant’s employing agency. The training school or agency shall assist in providing the required ATMS Global Profiles.

3.The training center director, agency administrator, or designee shall review the instructor’s background, credentials, and abilities and shall approve and sign the instructor certification application upon finding that the instructor’s credentials and abilities are satisfactory.

4.Upon approval, the training school or employing agency shall submit the approved application through the Commission’s ATMS and shall make the documentation available for review by Commission staff.

How to Complete Each Item:

1.Social Security Number. Enter the instructor’s nine-digit social security number as in this example: 000-00-0000.

2.Name. Enter the instructor’s legal name. Enter the instructor’s last and first name. If the instructor has a middle initial, enter it above “MI.”

3.Date of birth. Enter the instructor’s date of birth as in this example: 08-21-1962.

4.Ethnic group or race. Enter X in the box beside the instructor’s ethnic group or race. Read how ethnic groups and races are defined before placing an X in one of the boxes.

♦Hispanic: All persons of Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race. May be either white or black.

♦Asian or Pacific Islander: Originated from the original peoples of Far East, Southeast Asia, Indian Subcontinent, or Pacific Islands. (Examples are: China, Japan, Korea, Philippine Islands, and Samoa.)

♦American Indian or Native Alaskan: Originated from the original peoples of North America and maintain cultural identification through tribal affiliation or community recognition.

♦Black: Originated from the Black racial groups of Africa, but not of Hispanic origin or culture.

♦White: Originated from the original peoples of Europe, North Africa or Middle East, but not of Hispanic origin or culture.

♦Other: Individuals who are not Hispanic, Asian, Pacific Islander, American Indian, Native Alaskan, Black or White.

5.Sex. Enter X in the appropriate box.

6.Current Status. Enter X in the box that indicates the instructor’s current status. If the instructor is non-sworn or not currently employed as a sworn officer, the training school shall ensure that the instructor meets the requirements of Rule 11B-27.0011, F.A.C.

7.Employer. Enter the name of the training school, agency, school, or business where the instructor is employed. Enter N/A if unemployed.

8.Employer’s address. Enter the instructor’s employment address. Enter the street address, including the apartment or P.O. Box number, on the first line. Enter the city on the second line. Enter the state and nine-digit zip code on the third line. Enter the employer’s telephone number including the area code.

9.Instructor Applicant’s Contact Information. Enter the instructor applicant’s contact information.

10.Applying For New Certification, Adding Subjects, or Changing Affiliation. Attach the required documentation. Enter X in the box beside “New” if applying for new certification. If the instructor has a certification in one or more subjects and is applying for certification in additional subjects, enter X in the box beside “Add Subjects.” If the instructor is currently a certified instructor and requests to change his or her affiliation, enter “X” in the box beside “Change of Affiliation.”

11.Subject(s) for which you are applying for certification. Enter X in the box beside each subject for which the instructor is requesting CJSTC certification.

12.Applicant’s Signature. The applicant shall indicate the name of the affiliating agency or training school and shall read and sign this form. Instructor applications are not valid unless signed by the applicant.

Upon completion of items 1 – 12, the instructor shall submit this application to a Commission-certified criminal justice training school or employing agency.

13.Training Center Director, Agency Administrator, or designee’s signature. After verifying the applicant’s credentials and abilities, the training center director, agency administrator, or designee shall sign this form.

14.Enter the training center director, agency administrator, or designee’s printed name.

15.Enter the Training School or Employing Agency’s Name and Number or Agency ORI Number. Enter the affiliating training school’s name and two-digit training school number, or the employing agency’s name and ORI number. Example: FL0370000.

Upon completion of items 1-12, submit this application to a Commission- certified criminal justice training school or employing agency.