Form F 5C Doc PDF Details

The Form F-5C, known as the "Report of Appointment/Reinstatement of Certification," plays a pivotal role within the criminal justice system by documenting the employment and certification status of individuals after a permanent separation of up to two years. It captures extensive details, including personal information, offense history with law enforcement involvement, conviction dates, case dispositions, and probation statuses. The form demands honesty in reporting past misdemeanors, felonies, and even specifics about charges that are still pending. Notably, it distinguishes between minor traffic violations and more serious offenses such as DWI/DUI, emphasizing the need for complete transparency about one's criminal history. The documentation process extends to include personal acknowledgments regarding the accuracy of the information provided, the implications of any falsehoods, and the ongoing obligation to report any new criminal offenses. The form also contains sections for medical information, including psychological screenings and drug tests, further underscoring its thorough approach to assessing an applicant's suitability for certification or employment within North Carolina's Department of Corrections. With spaces for additional convictions or charges and detailed instructions for reporting, the F-5C form serves as a comprehensive tool for maintaining rigorous standards and accountability in the certification and employment processes within the corrections system.

QuestionAnswer
Form NameForm F 5C Doc
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesForm F5C north carolina form pd 107 fillable

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(a) Offense: ________________________________________Law Enf. Agency/County/State:_____________________________________
Date of Conviction: ______________________________ Disposition of Case:______________________________________________
Misdemeanor FelonyProbation Yes No (If yes, give details on the back of this form).
(b) Offense: ________________________________________Law Enf. Agency/County/State:_____________________________________
Date of Conviction: _______________________________Disposition of Case:_______________________________________________
Misdemeanor FelonyProbation Yes No (If yes, give details on the back of this form).
(c) Offense: ________________________________________Law Enf. Agency/County/State:_____________________________________
Date of Conviction: _______________________________ Disposition of Case:______________________________________________
Misdemeanor FelonyProbation Yes No (If yes, give details on the back of this form).
(List additional convictions or pending charges on the back of this form)
Pending Charges
No Criminal Convictions
Criminal Conviction Record: All convictions or pending charges 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. You should check the “Pending Charges” block if the case has not reached a disposition in court and give details. Check all that apply:
1.
Criminal Convictions as Reported Below
Date of Birth:____________________________
Social Security # _________________________

Criminal Justice Education And Training Standards Commission

Criminal Justice Standards Division

REPORT OF APPOINTMENT/ REINSTATEMENT OF CERTIFICATION

Form F-5C (DOC)

WITHIN TWO (2) YEARS AFTER PERMANENT SEPARATION

(08/2009)

 

 

 

For Criminal Justice Standards Use Only:

 

 

Certification: ________________________ TRA: ______________ FP: ______________

Mailed: _________________

 

 

 

 

Certification:

DOC Correctional Officer

DOC Probation/Parole

Name: _______________________________________________________

First

Middle

Last

DOC Surveillance

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

Effective Date (EOD): ___________________________ Position Title: ______________________________________

Criminal History:

Date Fingerprints Scanned/Rolled: ______________________________

 

Date DCI Checks Completed:

______________________________

Medical Information: Date Psychological Screening Conducted: _____________Authorized Psychologist: Ken Wilson, Psy.D.

 

(If N/A, applicant has been separated less than 12 months)

Date Negative Drug Test Reported: __________________ Name of HHS Certified Lab: LabCorp

 

 

 

 

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 above 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, pleads no contest to, pleads 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__

 

F-5C (DOC) REPORT OF APPOINTMENT/REINSTATEMENT OF CERTIFICATION

WITHIN TWO (2) YEARS AFTER PERMANENT SEPARATION

Side two (2) Continued

Please record additional convictions or pending charges below.

(d)Offense:______________________________________Law Enf. Agency/County/State:________________________________

Date of Conviction: ____________________________Disposition of Case:_________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details below).

(e)Offense: ______________________________________Law Enf. Agency/County/State:_______________________________

Date of Conviction: _____________________________Disposition of Case:_________________________________________

Misdemeanor

Felony

Probation

Yes

No (If yes, give details below).

(f)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)

2. Do you have any pending charges or a Domestic Violence Order?

Yes

No (If yes, give details below or on a separate sheet).

Please record a brief explanation for each question that you answered “Yes” and, therefore, an explanation was requested. Please be sure to record the corresponding question number next to each explanation below.

Question # and Explanation:

Applicant Signature: _______________________________________

Date: _________________________

I, as an official representative of the appointment agency, do submit to the Commission the 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 file 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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