Psb 00 Form – Fill Out and Use This PDF

PEACE OFFICER TRAINING CERTIFICATION & FINGERPRINT WAIVER

Company

Company

Name

License No.

Applicant Social

-

-

 Driver License

DL/ID

DL/ID

Security Number



ID Card

State:

No.

Last Name of

First

M.I.

Suffix

Peace Officer

Name

(If Any)

Gender:

Male



Date of Birth

/

/

TCLEOSE PID Number

Female



(MM/DD/YYYY)

	I have reviewed and am familiar with Chapter 1702 of the Texas Occupations Code and related Administrative Rules.	Yes	
		No	
	COMPLETE EITHER PART I. OR PART II.
	PART I. ACTIVE PEACE OFFICER ONLY
	I am a Full-Time Peace Officer certified by the Texas Commission on Law Enforcement Officer Standards and Education (TCLEOSE).	Yes	
		No	
	I am employed at least 32 hours per week by a Texas Law Enforcement Agency.	Yes	
		No	

PART II. RETIRED PEACE OFFICER ONLY (MUST BE “HONORABLY RETIRED” WITHIN THE LAST TWO (2) YEARS)

	Date of Retirement	/	/	I certify that within the last 2 years I became an Honorably Retired Peace Officer certified by	Yes	
				the Texas Commission on Law Enforcement Officer Standards and Education (TCLEOSE).	No	
	(MM/DD/YYYY)
	As proof of my retirement, I am submitting documentation from the Employing Agency or from the Texas Commission on Law Enforcement				Yes	
	Officer Standards and Education (TCLEOSE).				No	

BOTH ACTIVE AND RETIRED PEACE OFFICERS MUST PROVIDE THE FOLLOWING:

FINGERPRINT INFORMATION

I attest that my fingerprints are on file with the following agency:

Employing Law Enforcement Agency

(OR Agency Retired From)

	Agency’s		Phone (	)
	Address
	City	State	ZIP
		(2- Digit Code)

I verify that the information provided is true and correct, and I understand that this is an official Government record and that any false statement made on this document or any other supplement provided to the Department may result in criminal prosecution.

Signature________________________________________________ Date____ /____ /________

Signature on this form may be accepted as a substitute for the signature on the application form.

This form and attachments can be Faxed to (512) 424-7726 or forwarded by mail to:

Texas Department of Public Safety

Private Security MSC 0242

PO Box 4087

Austin, TX 78773-0001

PSB-00 (Rev. 12/2011)

FORM

Note: Applicant is not required to submit Page 2 of this form.

PRIVACY POLICY:

Sec. 559.003. RIGHT TO NOTICE ABOUT CERTAIN INFORMATION LAWS AND PRACTICES.

(a)Each state governmental body that collects information about an individual by means of a form that the individual completes and files with the governmental body in a paper format or in an electronic format on an Internet site shall prominently state, on the paper form and prominently post on the Internet site in connection with the electronic form, that:

(1)with few exceptions, the individual is entitled on request to be informed about the information that the state governmental body collects about the individual;

(2)under Sections 552.021 and 552.023 of the Government Code, the individual is entitled to receive and review the information; and

(3)under Section 559.004 of the Government Code, the individual is entitled to have the state governmental body correct information about the individual that is incorrect.

(b)Each state governmental body that collects information about an individual by means of an Internet site or that collects information about the computer network location or identity of a user of the Internet site shall prominently post on the Internet site what information is being collected through the site about the individual or about the computer network location or identity of a user of the site, including what information is being collected by means that are not obvious.

Found at: http://www.statutes.legis.state.tx.us/docs/GV/htm/GV.559.htm

PSB-00 (Rev. 12/2011)

FORM