Form F 5A – Fill Out and Use This PDF

Criminal Justice Education and Training Standards Commission

Criminal Justice Standards Division

	Form F-5A(DOC)
REPORT OF APPOINTMENT/APPLICATION FOR CERTIFICATION	Revised (08/2009)
For Criminal Justice Standards Use Only:
Certification: ________________________ TRA: ______________ FP: ______________	Mailed: _________________

Name: _____________________________________________			Social Security # _______________________
First	Middle	Last
			Date of Birth: __________________________

Military Service: If you have ever served in the U.S. Military or been a member of any military organization, please complete Questions 4-5.

4.	What was your last discharge? Date: _____________	Honorable	General	Dishonorable	Other: ______________
5.	Were you ever court-martialed, tried on charges, or were you the subject of a summary court, deck court, or nonjudicial				Yes	No
	punishment (Captain’s mast, company punishment, Article 15, etc.) or any other disciplinary action? (If yes, please give details on a separate
	sheet).

Criminal Conviction Record: All convictions other than minor traffic violations must be reported in the applicant’s own handwriting below. Please note that a “DWI/DUI (alcohol or drugs),” “Duty to Stop in the Event of an Accident,” and “Speeding to Elude Arrest” are NOT minor traffic violations and, therefore, MUST be reported below. Provide all information completely and accurately. Any falsifications or misstatements of fact may be sufficient to disqualify you. If any doubt exists in your mind as to whether you were convicted of a criminal offense at some point in your life, you should check the block labeled, “Criminal Convictions as Reported Below” and give details. You should check the “No Criminal Convictions” block ONLY if you have never been convicted of a Misdemeanor or Felony, or your record/citation was expunged by a judge’s court order. Check one of the following:

6.

No Criminal Convictions

Criminal Convictions as Reported Below

(a)Offense: ________________________________________Law Enf. Agency/County/State:______________________________________

Date of Conviction: ______________________________ Disposition of Case:______________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details on Page 3).

(b)Offense: ________________________________________Law Enf. Agency/County/State:_____________________________________

Date of Conviction: _______________________________Disposition of Case:_______________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details on Page 3).

(c)Offense: ________________________________________Law Enf. Agency/County/State:_____________________________________

Date of Conviction: _______________________________ Disposition of Case:______________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details on Page 3).

(d)Offense: ________________________________________Law Enf.Agency/County/State:______________________________________

Date of Conviction: ______________________________ Disposition of Case:______________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details on Page 3).

(e)Offense: ________________________________________Law Enf. Agency/County/State:_____________________________________

Date of Conviction: _______________________________Disposition of Case:_______________________________________________

Misdemeanor	Felony	Probation	Yes	No (If yes, give details on Page 3).
		(List additional convictions on Page 3)

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Form F-5A (DOC) report of appointment/application for certification

SIDE TWO (2) CONTINUED

Report of Appointment (To be completed by the Regional Employment Office ONLY):

Beacon # _________________

Position Title: ______________________________________ Effective Date (EOD): ____________________________

This section must be completed indicating requirements of the Administrative Code (12 NCAC 9G) have been met with necessary forms and documentation having been placed in applicant’s personnel file prior to appointment. Failure to complete any item will result in the return of this form.

Education Information:
High School Verified :		Diploma	GED Report	Transcript		Other: ______________
College Verified:	Diploma	Degree Verification		Transcript	Other: ______________
College Degree: Type of Degree Awarded (AAS,BA,BS,etc.)______________________________________________
Criminal History:	Date Fingerprints Scanned/Rolled: ___________________________
	Date DCI Checks Completed:			___________________________

Medical Information:

Date Psychological Screening Conducted: ________________ Authorized Psychologist: Ken Wilson, Psy.D.

Date Negative Drug Test Reported: _____________________ Name of HHS Certified Lab: LabCorp___________

Date Physical Exam Conducted: ______________________

Name of Physician/Physician Assistant/Nurse Practitioner: ______________________________________________

STATE OF NORTH CAROLINA

COUNTY OF: ________________________________

I hereby certify that each and every statement made on this form, and the N. C. State Application for Employment (PD-107) is true and complete. As the applicant for certification, I attest that I am aware of the minimum standards for employment, that I meet each of those requirements, that the information provided and all other information submitted by me, both oral and written throughout the employment certification process is accurate to the best of my knowledge. I further understand and agree that any omission, falsification, or misrepresentation of any factor or portion of such information can be the sole basis for termination of my employment and/or denial, suspension or revocation of my certification at any time. I further understand that I have a continuing duty to notify the Commission of all criminal offenses which I am arrested for or charged with, plead no contest to, plead guilty to or am found guilty of. I acknowledge by my signature that my continued employment and certification are contingent on the results of the fingerprint record check and other criminal history records being consistent with the information provided in my State Application.

Subscribed and sworn to before me,	This the _______ day of __________________, 20__
this the _______ day of ______________, 20__
___________________________________	____________________________________________
Notary Public (Official Seal)	(Applicant’s Signature in Full)
My Commission Expires: _____________________, 20__

I, as an official representative of the appointing agency, do submit to the Commission the above-named appointee as a candidate for certification. The candidate meets or exceeds each of the minimum standards for employment and this agency has properly conducted the required employment procedures as established by the Commission and incorporated into 12 NCAC 9G. All documents necessary to insure compliance with the rules of the Code are being retained in the personnel files of this agency and may be inspected at any reasonable time by representatives of the Commission. I acknowledge that any omission, falsification, or misrepresentation of information or procedures, by either the candidate or this Agency, throughout the employment and/or certification process may result in certification being denied, suspended or revoked by the Commission at any time, now or later, and may result in sanctions against this Agency.

____________________________________________________	_________________________________________
Signature of Executive Officer or Registered Authorized Representative	Date

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(Note: Continuation of Question #6 from Page One. Complete if necessary.)

Criminal Conviction Record: All convictions other than minor traffic violations must be reported in the applicant’s own handwriting below. Please note that a “DWI/DUI (alcohol or drugs),” “Duty to Stop in the Event of an Accident,” and “Speeding to Elude Arrest” are NOT minor traffic violations and, therefore, MUST be reported below. Provide all information completely and accurately. Any falsifications or misstatements of fact may be sufficient to disqualify you. If any doubt exists in your mind as to whether you were convicted of a criminal offense at some point in your life, you should check the block labeled, “Criminal Convictions as Reported Below” and give details. You should check the “No Criminal Convictions” block ONLY if you have never been convicted of a Misdemeanor or Felony, or your record/citation was expunged by a judge’s court order. Check one of the following:

(f) Offense: ________________________________________Law Enf. Agency/County/State:______________________________________

Date of Conviction: ______________________________ Disposition of Case:______________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details below).

(g) Offense: ________________________________________Law Enf. Agency/County/State:_____________________________________

Date of Conviction: _______________________________Disposition of Case:_______________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details below).

(h) Offense: ________________________________________Law Enf. Agency/County/State:_____________________________________

Date of Conviction: _______________________________ Disposition of Case:______________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details below).

(i) Offense: ________________________________________Law Enf.Agency/County/State:______________________________________

Date of Conviction: ______________________________ Disposition of Case:______________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details below).

(j) Offense: ________________________________________Law Enf. Agency/County/State:_____________________________________

Date of Conviction: _______________________________Disposition of Case:_______________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details below).

(List additional convictions or pending charges on a separate sheet)

Question # and Explanation:

Applicant Signature: ______________________________	Date: _________________________
__________________________________________________________		__________________________
Signature of Executive Officer or Registered Authorized Representative		Date

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