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Question | Answer |
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Form Name | Form F 5C Doc |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | Form F5C north carolina form pd 107 fillable |
Criminal Justice Education And Training Standards Commission
Criminal Justice Standards Division
REPORT OF APPOINTMENT/ REINSTATEMENT OF CERTIFICATION |
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WITHIN TWO (2) YEARS AFTER PERMANENT SEPARATION |
(08/2009) |
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For Criminal Justice Standards Use Only: |
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Certification: ________________________ TRA: ______________ FP: ______________ |
Mailed: _________________ |
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Certification: |
DOC Correctional Officer |
DOC Probation/Parole |
Name: _______________________________________________________ |
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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: ______________________________ |
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Date DCI Checks Completed: |
______________________________ |
Medical Information: Date Psychological Screening Conducted: _____________Authorized Psychologist: Ken Wilson, Psy.D.
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(If N/A, applicant has been separated less than 12 months) |
Date Negative Drug Test Reported: __________________ Name of HHS Certified Lab: LabCorp |
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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
Subscribed and sworn to before me, |
This the _____ day of _________________, 20__ |
This the ______day of ____________, 20__ |
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___________________________________ |
_________________________________________ |
Notary Public (Official Seal) |
(Applicant’s Signature in Full) |
My Commission Expires: ____________________,20__ |
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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.
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Signature of Executive Officer or Registered Authorized Representative |
Date |