PERSONAL HISTORY STATEMENT

Transcription

1 Capital Area Council of Governments Regional Law Enforcement Academy 6800 Burleson Road Information: (512) Bldg 310, Suite Austin, Texas PERSONAL HISTORY STATEMENT Basic Peace Officer Certification Program Full Time Day Course Part Time Evening Course Please mark your preferred course. Submit the completed Personal History Statement to CAPCOG s Regional Law Enforcement Academy by mail to the above listed address, or you may scan and it to bpoc@capcog.org. For use by CAPCOG s Regional Law Enforcement Academy only: Date Received by Academy: Received by: Program Number:

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29 CHECK LIST NAME: Personal History Statement Emergency Contacts form Photocopy of Valid Texas Driver s License Certification of Basic Requirements TCLEOSE Form C-1 FAST-FORM Background Check Results (TCN # ) Tuition Policy MEDICAL FORMS: FORM L-2 Declaration of Medical Condition CAPCOG RLEA MEDICAL SCREENING FORM ORIGINAL DRUG SCREEN RESULTS FORM L-3 Declaration of Psychological and Emotional Health (Need MMPI) EDUCATION AND MILITARY: COPY OF COLLEGE TRANSCRIPT COPY OF HIGH SCHOOL TRANSCRIPT COPY OF G.E.D COPY OF (DD214) with HONORABLE DISCHARGE, IF APPLICABLE (Students hoping to use G.I. Bill Benefits must also submit military transcripts, all education transcripts, and Letter of Eligibility from the VA.) Military Transcripts Will you be using the G.I. Bill? Post 911? Montgomery? Letter of Eligibility? UNIFORM: ACADEMY SHIRT AND P.T. ORDER FORM PAYMENTS: UNIFORM PAYMENT $, Check # (Money Order or Cashier s Check only - made out to Beverly Johnson) TUITION (plus books and supplies): $ 2, (to CAPCOG RLEA) Credit Card: Cashier s Check: Money Order: #: RECEIVED BY: Date:

30 Emergency Contacts Student Name: Emergency Contact #1 Name Relationship Work Phone Home Phone Cell Phone Emergency Contact #2 Name Relationship Work Phone Home Phone Cell Phone Personal Doctor Doctor's Name Clinic or Hospital Office Address City State Zip Office Phone After Hours or Other Phone

31 Approximate Costs to Attend the Academy Do not Purchase Equipment until you are accepted into the academy! Qualifications Phase Criminal History Background Check $9.95 Physical $75.00 Drug Screen $50.00 Psychological/Emotional Evaluation (MMPI) $ Tuition $2, Books & Supplies $ Daily Uniform: (incurred prior to start of class) Polo Shirts (from CAPCOG's Vendor Beverly Johnson) $ Black BDU Rip Stop poly/cotton Pants(banana bay) $75.00 Garrison Belt (black, leather, 2" wide, buckle is square & silvertone) $20.00 Police Tactical Boots (must lace up, zipper ok, able to polish toe) $90.00 Duty Rig: (incurred mid course) Duty Belt (may be mesh) $25.00 Duty Belt keepers (set of 4) $10.00 Handcuffs Case $15.00 Collapsible Baton Holder $10.00 Double Magazine Holder $20.00 Handcuffs (chain or hinge)(black, silver, gray) $30.00 Holster $50.00 Weapons and Ammunition: (Incurred mid course) ASP Baton (expandable) $ Handgun (full size, 40, 45, 9mm, 357 Sig)(must be min 4" barrell) $ rounds ammunition $ rounds buckshot (OO or OOO) $25.00 Additional Supplies: Mouthpiece $2.00 Running shoes (optional) $30.00 Misc. office supplies $30.00 Approximate Total to attend the BPOC: $4,066.95

32 Capital Area Council of Governments Regional Law Enforcement Academy CERTIFICATION OF BASIC REQUIREMENTS I hereby certify, by my signature, that I understand and meet the basic requirements set by CAPCOG and the Texas Commission on Law Enforcement Standards and Education (TCLEOSE) for entrance into the Basic Peace Officer Certification Course (or Police Academy) as follows: AGE: I am at least 21 years of age or will be 21 years of age the end of the academy. PHYSICAL: I am able to physically perform the job of a Peace Officer EDUCATION: I have one or more of the following qualifications and will provide transcripts for all education. o High School Diploma o GED and 12 credit hours from an accredited college or university o A Bachelor s Degree from an accredited college or university o 2 years of Active Military Service with an Honorable Discharge MILITARY HISTORY: o Any military service, of any duration, must have a discharge characterized as Honorable. o An applicant with military service, of any duration, must provide a photocopy of his or her DD-214 (member) page 4, with the discharge characterization posted. CRIMINAL HISTORY: o I have not been convicted of a Class B Misdemeanor within the past 10 years. o I have never been convicted of a Class A Misdemeanor. o I have never been convicted of a Felony. o I have no pending Class B Misdemeanors, Class A Misdemeanors, or Felonies. Furthermore, I also understand that I must meet the following criteria before entering CAPCOG s Basic Peace Officer Certification course: Take and Pass a Peace Officer Employment physical Maintain a VALID Texas Driver s License (if you have an out of state license, you must apply for a Texas license) Pass a Psychological/Emotional evaluation called an MMPI with a licensed Psychologist Pass a 10-Panel Drug Screen Pass a State and Federal Criminal History Applicant s Signature: Applicant s Name (printed): Date: ~CAPCOG s Basic peace Officer Certification Program is funded in part by the Governor s Office, Criminal Justice Division.~

33 TEXAS COMMISSION ON LAW ENFORCEMENT OFFICER STANDARDS AND EDUCATION 6330 E Highway 290, STE 200 Austin, Texas Phone: (512) PID ASSIGNMENT (C-1) Completion of all fields required INDIVIDUAL INFORMATION 1. Social Security Number 2. First Name 3. M.I. 4. Last Name 5. Suffix (Jr., etc.) 6. Race / Ethnicity American Indian or Alaskan Native Asian Black Hispanic Multicultural White 7. Date of Birth / / 8. Gender Male Female 9. Driver s License State: 10. Home Mailing Address 11. City 12. State 13. Zip Code Num.: 14. Height 15. Weight 16. Hair Color 17. Eye Color 18. U.S. Citizen Yes No 19. Phone Number (include area code) 20. This form is to be submitted only for the express purpose of having a personal identification number (PID) assigned by TCLEOSE to the above named individual therein creating a TCLEOSE record and allowing training to be reported for that individual. Academy or chief administrators check appropriate box for their student or employee. Applying for entry into a Law Enforcement Academy Future appointment as a Telecommunicator, Temporary or Licensed Future appointment as a County or Contract Jailer, Temporary or Licensed Future Appointment as a Probation Officer, Juvenile or Adult Ability to track training hours Director Michael Jennings, CAPCOG Regional Law Enforcement Academy Date Individuals not associated with academy or agency check below. Applying for instructors certificate Applying for Retired Federal Firearms ID Applying for an out of state, federal, military police or TDCJ endorsement Applicant (Type or Print) Signature Date PID Assignment Page 1 of 1

34 Completing the Physical and Drug Screen Portion of the Application INSTRUCTIONS: 1. The medical documentation for entering CAPCOG s Basic Peace Officer Certification course consists of the following: a. Medical Questionnaire b. Medical Screening Form c. TCLEOSE Form L 2, Licensee Medical Condition Declaration d. Results from a Urinalysis for Illicit Drugs (10 panel drug screen) 2. The applicant will complete the Medical Questionnaire and the top portion of Form L 2 prior to attending the medical appointment. The Physician will complete the bottom portion of Form L 2 and CAPCOG s Medical Screening form after the physical and drug screen are performed. 3. The applicant must make and attend an appointment with a Licensed Texas Physician and request the following: a. A Peace Officer Physical b. A 10 Panel Drug Screen (the physician may send the applicant to another facility for testing) 4. If a Physician s Assistant or Nurse performs the actual physical, then the overseeing Physician must sign off on the exam. The applicant will leave the paperwork with the physician until the drug screen is completed. 5. The Drug Screen may take a few days to be completed after the original submission of urine. When it is completed, the Lab submits the results to the requesting Physician. NOTE: The same physician who signs off on the exam must review the lab results and sign off on the Drug Screen. 6. Following the Physical and Drug Screen, the applicant must request that he/she be given the original results of the Urinalysis. If the medical office personnel cannot provide that to the applicant, then the medical office may fax or the results to CAPCOG RLEA. 7. The applicant will return the completed documents as listed above to CAPCOG RLEA along with the drug screen results by the stated deadline. Capital Area Council of Governments Regional Law Enforcement Academy Contact: Stephanie Johnston, Administrative Assistant 6800 Burleson Road, Bldg 310 Ste 165 Austin, Texas sjohnston@capcog.org Phone: (512) Fax: (512)

35 TEXAS COMMISSION ON LAW ENFORCEMENT OFFICER STANDARDS AND EDUCATION 6330 E. Highway 290, STE. 200 Austin, Texas Phone: (512) LICENSEE MEDICAL CONDITION DECLARATION (L-2) Commission Rule (c), 217.1(a)(11), 217.7(e) 1. TCLEOSE PID or SSN INDIVIDUAL INFORMATION 2. Last Name. 3. First Name 4. M.I. 5. Suffix (Jr., etc.) 6. Home Mailing Address 7. City 8. State 9. Zip Code Is this exam for a student enrolling in an academy? Yes No If yes, check one Peace Officer County Corrections APPOINTMENT( Do not check if student) 10. Peace Officer Reserve Officer County Jailer Public Security Officer 11. TCLEOSE N u m b e r C i t y Austin DEPARTMENT / ACADEMY INFORMATION 12. Appointing Agency or Academy Capital Area Council of Governments Regional Training Academy 15. County Travis 13. Mailing Address 6800 Burleson Rd, Bldg 310, Ste Zip Code Phone Number (512) Attention Examining Professional: The above information must be completed by the requesting agency prior to the examining professional completing and signing this form. NEW APPLICANTS MUST COMPLETE BOTH EXAMS LICENSEE(S) OFFICER(S) WITH MORE THAN A 180 DAY BREAK IN SERVICE NEED(S) DRUG SCREEN ONLY I certify that I have completed my examination of the examinee and I have concluded that on this date, the examinee is found: Check the appropriate box(s) PHYSICAL EXAM - To be physically sound and free from any defect which may adversely affect the performance of duty appropriate to the type of license sought. DRUG SCREEN - To show no trace of drug dependency or illegal drug use after a physical examination, blood test or other medical test. Physician s Name (type or print) State License Number Mailing Address Street City State Zip Phone Number Date of Examination(s) Physician s Signature Date THIS DECLARATION IS NOT PUBLIC INFORMATION AND IS VALID UNLESS WITHDRAWN OR INVALIDATED, AND IS VALID ONLY IF SIGNED BY A LICENSED PHYSICIAN. Licensee Medical Condition Declaration Page 1 of 1

36 Capital Area Council of Governments Regional Law Enforcement Academy 6800 Burleson Road, Bldg 310 Suite 165 Austin, Texas Phone, Fax MEDICAL QUESTIONAIRE 1. Are you physically able to perform the duties of a Peace Officer? Duties would include running, jumping, bending, sitting, standing, driving, and performing physical exercise. Yes No If no, please explain: 2. Has any member of your family suffered a stroke or heart attack prior to the age of 50? Yes No 3. Do you often suffer from severe dizziness? Yes No 4. Have you ever been diagnosed with high blood pressure? Yes No 5. Do you have frequent chest/heart pains? Yes No 6. Have you ever been diagnosed with heart problems? Yes No 7. Do you experience extreme shortness of breath after mild exertion? Yes No 8. Do you have orthopedic or arthritic problems that might be aggravated by exercise? Yes No 9. Have you ever experienced heat stroke or heat related illness? Yes No 10. Do you have asthma? Yes No 11. Do you have high cholesterol? Yes No 12. Are you presently on any medications? Yes No 13. Do you smoke? Yes No If yes, how many packs per day? 14. Do you have any physical impairment that would prevent you from participating in a physical fitness program or from participating in physical confrontation training? Yes No If you answered Yes to any of the medical related questions, please explain here and list all prescription medications: 1

37 MEDICAL SCREENING FORM (to be completed by the physician who completes the L 2 form) The applicant being examined by you is about to enter rigorous police training that will require instruction and physical conditioning. The Peace Officer s job may involve standing for long hours, stooping, bending, lifting, and running over various terrains and up flights of stairs. The physical training during the academy will consist of basic calisthenics and running or fast walking of up to two miles. If you believe the applicant is physically sound enough to participate in this program, please complete this form. APPLICANT NAME: AGE SEX: WEIGHT: HEIGHT: RESTING HEART RATE: ARRHYTHMIA: RESTING SYSTOLIC: RESTING DIASTOLIC: I certify that the applicant above is physically sound enough to participate in the physical training portion program of the Basic Peace Officer Course: Physician s Signature Printed Name License Number Date 2

38 Completing the Psychological and Emotional Evaluation Portion of the Application INSTRUCTIONS: 1. The Psychological and emotional Evaluation portion of the Application for entering CAPCOG s Basic Peace Officer Certification course consists of completing and passing a test called a Minnesota Multiphasic Personality Inventory, or MMPI. 2. The applicant must make and attend an appointment with a Licensed Texas Psychologist or Psychiatrist who is qualified to evaluate law enforcement personnel. Please refer to the attached references. 3. The applicant must complete the top portion of the TCLEOSE Form L 3, Licensee Psychological and Emotional Health Declaration, prior to attending the appointment 4. After the test, the doctor will score the test, and complete the L The doctor may give the original L 3 to the cadet or fax or to CAPCOG RLEA. NOTE: If you are currently employed as a corrections officer, you should check with your human resources personnel to determine if the L 3 on file is for Peace Officer or for County Corrections. If it is for Peace Officer, then you may submit a copy of that L 3 along with a letter from your agency stating your employment status instead of taking the MMPI all over again. However, if you are not employed or have an L 3 for County Corrections, then you must take and pass the MMPI. Capital Area Council of Governments Regional Law Enforcement Academy Contact: Stephanie Johnston, Administrative Assistant 6800 Burleson Road, Bldg 310 Ste 165 Austin, Texas sjohnston@capcog.org Phone: (512) Fax: (512)

39 TEXAS COMMISSION ON LAW ENFORCEMENT OFFICER STANDARDS AND EDUCATION 6330 E. Highway 290, STE 200 Austin, Texas Phone: (512) LICENSEE PSYCHOLOGICAL AND EMOTIONAL HEALTH DECLARATION (L-3) Commission Rule (c), (a)(12) 1. TCLEOSE PID or SSN INDIVIDUAL INFORMATION 2. Last Name 3. First Name 4. M.I. 5. Suffix (Jr., etc.) 6. Home Mailing Address 7. City 8. State 9. Zip Code Is this exam for a student enrolling in an academy? Yes No If yes, check one Peace Officer County Corrections Attention Requesting Agency: State Law and Commission Rule require that this psychological examination be performed by a licensed psychologist or a psychiatrist except in an exceptional circumstance when, upon prior approval by the Commission, it may be performed by a qualified licensed physician. The Chief Administrator of the requesting law enforcement agency must request prior approval in writing and must receive specific written approval before an examination under exceptional circumstances is acceptable. APPOINTMENT (Do not check if student) 10. Peace Officer Reserve Officer County Jailer Public Security Officer ACADEMY / DEPARTMENT INFORMATION 11. TCLEOSE N u m b e r Agency/Academy Name Capital Area Council of Governments 14. C i t y Austin Regional Training Academy 15. County Travis 13. Mailing Address 6800 Burleson Rd, Bldg 310, Ste Zip Code Phone Number (512) Attention Examining Professional: State Law and Commission Rule require that this psychological examination be performed by a licensed psychologist or a psychiatrist except in an exceptional circumstance when, upon prior approval by the Commission, it may be performed by a qualified licensed physician. The law enforcement agency must request prior approval in writing and must receive specific written approval before an examination under exceptional circumstances is acceptable. STATEMENT OF EXAMINER: (Please check the appropriate box and provide the requested information) I am a [ ] Licensed Psychologist, [ ] Psychiatrist, and I certify that I have completed a psychological examination of the above named individual pursuant to professionally recognized standards and methods. I have concluded that, on this date, the individual IS in satisfactory psychological and emotional health to perform the duties, accept the responsibilities and meet the qualifications established by the appointing agency. Examiner: Name (type or print) State License Number Mailing Address: Street City State Zip Phone Number: Date of Examination(s) Signature Date THIS DECLARATION IS NOT PUBLIC INFORMATION AND IS VALID UNLESS WITHDRAWN OR INVALIDATED, AND IS VALID ONLY IF SIGNED BY A LICENSED PSYCHOLOGIST OR PHYSICIAN. Licensee Psychological and Emotional Health Declaration Page 1 of 1

40 Completing the TCIC/NCIC (Criminal History) Portion of the Application INSTRUCTIONS: 1. The criminal history portion of the Application for entering CAPCOG s Basic Peace Officer Certification course consists of submitting your electronic fingerprints to FAST and completing and passing a TCIC/NCIC, or Texas and National Crime Information Center search through TCLEOSE. 2. The applicant will make an appointment with FAST by following the directions at the top of the form. 3. FAST will take your electronic fingerprints and submit them to the TxDPS/FBI. The results will be submitted to TCLEOSE. 4. TCLEOSE will evaluate the information and notify CAPCOG RLEA of the results. TCLEOSE will not give your information to CAPCOG RLEA staff they will only notify as to Qualified or Not Qualified. NOTE: If you are notified by CAPCOG RLEA that TCLEOSE has deemed you Not Qualified, you must then call TCLEOSE at to inquire about the reason. In order to resolve errors with your criminal history, you may contact the TxDPS Error Resolution Unit at , or go to to obtain resolution request forms. Capital Area Council of Governments Regional Law Enforcement Academy Contact: Stephanie Johnston, Administrative Assistant 6800 Burleson Road, Bldg 310 Ste 165 Austin, Texas sjohnston@capcog.org Phone: (512) Fax: (512)

41 TCLEOSE ACADEMY This document is your FAST Fingerprint Pass for a national criminal history record check. Please schedule a fingerprint appointment by visiting or by calling You must pay the $9.95 fee for FAST services online with a credit card or onsite with a check or money order. Cash is not accepted! 1. Logon to 2. Select: Texas 3. Select: Online Scheduling 4. Select: English or Espanol 5. Enter: First and Last Name Section One: Qualified Entity Information 6. Select: TCLEOSE 7. Enter: TX923466Z 8. Enter: Academy Provider Number, LE Follow the prompts to enter requested information. 10. Bring this completed form with you to your appointment. TCLEOSE ORI#: TX923466Z Academy Provider Number: Original TCN: (If resubmission for rejected fingerprints) Attending police agency-owned academy Attending non-police agency-owned Academy Jailer Hiring Agency or Academy Name: Capital Area Council of Governments Regional Law Enforcement Academy (CAPCOG RLEA) Hiring Agency or Academy Address: 6800 Burleson Road, Building 310 Suite 165 Austin, Texas Street Address City State Zip Section Two: Applicant Name (To be completed by applicant) Last: First: Middle: (Please print) (Please print) (Please print) Section Three: Waiver Information (To be signed by applicant) I certify that all information I provided in relation to this criminal history record check is true and accurate. I authorize the Texas Department of Public Safety (DPS) to access Texas and Federal criminal history record information that pertains to me and disseminate that information to the designated Authorized Agency or Qualified Entity with which I am or am seeking to be employed or to serve as a volunteer, through the DPS Fingerprint-based Applicant Clearinghouse of Texas and as authorized by Texas Government Code Chapter 411 and any other applicable state or federal statute or policy. I authorize the Texas Department of Public Safety to submit my fingerprints and other application information to the FBI for the purpose of comparing the submitted information to available records in order to identify other information that may be pertinent to the application. I authorize the FBI to disclose potentially pertinent information to the DPS during the processing of this application and for as long hereafter as may be relevant to the activity for which this application is being submitted. I understand that the FBI may also retain my fingerprints and other applicant information in the FBI s permanent collection of fingerprints and related information, where all such data will be subject to comparisons against other submissions received by the FBI and to further disseminations by the FBI as may be authorized under the Federal Privacy Act (5USC 552a(b)). I understand I am entitled to obtain a copy of any criminal history record check and challenge the accuracy and completeness of the information before a final determination is made by the Qualified Entity. I also understand the Qualified Entity may deny me access to children, the elderly, or individuals with disabilities until the criminal history record check is completed. Signature: Date: Section Four: Service Center Information (To be completed by FAST Enrollment Officer) Date Prints Taken Amount Charged For Service: _$9.95 Paid by: Check Money Order Visa MasterCard Billing Acct TCN: I HAVE COMPARED THE GOVERNMENT-ISSUED IDENTIFICATION PRESENTED BY THE APPLICANT AND ATTEST THAT TO MY BEST DETERMINATION; I HAVE FINGERPRINTED THE SAME PERSON. E.O. Name: (Please print) E.O. Signature: Revised 01/10

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