LEOSA Retiree Registration Form - Columbia County Sheriff`s Office

“An Internationally Accredited Agency”
COLUMBIA COUNTY SHERIFF’S OFFICE
Clay N. Whittle, Sheriff
2273 COUNTY CAMP ROAD
POST OFFICE BOX 310
APPLING, GEORGIA 30802-0310
(706) 541-1043
LEOSA Retiree Registration Form
Date Requested: ______________________
Date: ______________
Date: ______________
By: ______________________
__________________
By: ______________________
__________________
Name
Name
Retirement Date:________________
ID #
ID #
tire
Retirement Agency ____________________________ Agency Contact ______________________________
Phone Number ________________________________ E-Mail Address________________________________
Current Handgun Permit?
Y
If Yes: _____________________________ ____________
Permit Number
State
Driver’s License Number: ___________________ State: ___________ Expiration Date:________________
Name: ____________________________________________________
Last
First
Middle
SSN: _________________________
Address: __________________________________________________________________________________
Street
Sex:
M
City, State
County
Zip
F Race: ____ DOB: ______________ Hgt: ____ Wgt: ____ Eye Color: _____ Hair Color: _____
MM/DD/YYYY
Phone: __________________
Home
___________________
Other
Email Address:_______________________
Type of Weapon:________________ Make:___________ Model:__________ Serial #:___________________
Type of Weapon:________________ Make:___________ Model:__________ Serial #:___________________
1.
2.
3.
4.
5.
Have you ever been LEOSA certified by the Columbia County Sheriff’s Office?
Have you ever been served with an ex-parte or protection order for domestic violence?
Have you ever been charged with, arrested for, or convicted of any violation of criminal law?
Did you retire for reasons of mental instability?
Have you ever been confined or committed to a mental institution or hospital for treatment or
observation for a mental or psychiatric condition on a temporary or permanent basis?
6. Have you ever been attended, treated, or observed by any medical doctor, psychiatrist, hospital, or
institution, including voluntary commitment, for any mental or psychiatric condition?
7. Are you addicted to or have you ever been addicted to alcohol, any controlled dangerous substances,
or dangerous substances; or are you currently being treated for alcoholism, addiction to controlled
dangerous substances, or addiction to any dangerous substances?
ON ATTACHED CONTINTUATION FORM, PLEASE INCLUDE THE FOLLOWING:
A. If you answered YES to any of the above questions, please provide detailed explanation of each.
Current as of 10-27-15
B. Give full details of prior denial, suspension, revocation, or termination of your handgun permit, license, certification
or registration in Georgia or any other state or jurisdiction.
C. You are required to report on the continuation sheet if you are on parole, probation, or mandatory supervision.
AFFIDAVIT
Name:____________________________________________________________________________________
Last
First
Middle
Before Retirement (check one):
_____
I was regularly employed as a law enforcement officer for ten (10) or more years aggregated.
_____ I retired after completing probation due to a service-connected disability as determined by the agency I
retired from.
Please read and initial next to each of the below statements:
_____ I understand that in order to carry a concealed firearm as a qualified retired law enforcement officer in accordance
with the Law Enforcement Officers Safety Act of 2004, 18 U.S. C. 926C, I must satisfy certain basic criteria.
My satisfaction of the certification criteria will be established based on my answers to these questions.
_____ I was authorized to engage in or supervise the prevention, detection, investigation, or prosecution of, or
incarceration of any person for any violation of law, and I had statutory powers of arrest.
_____ I have non-forfeitable rights to benefits under my agency’s retirement plan.
_____ I am not under the influence of alcohol or another intoxicating or hallucinatory drug or substance, and I will not
carry a firearm while I am under the influence of alcohol or another intoxicating or hallucinatory drug or
substance.
_____ I am not prohibited by state or federal law from receiving a firearm.
_____ I understand that the definition of firearm does not include any machine gun, firearm silencer, or destructive
device.
_____ I understand that I must carry my Georgia POST LEOSA card along with my photo ID issued by my agency when
I carry a concealed weapon.
_____ I understand that my LEOSA certification expires twelve (12) months from its issue date.
_____ I understand that my Law Enforcement Officers Safety Act of 2004, 18 U.S.C. 926C, does not give me any rights
whatsoever to exercise law enforcement authority or take police action under any circumstances.
AUTHORIZATION AND RELEASE:
I do hereby declare and affirm under penalties of perjury that the contents of this application are true and correct
to the best of my knowledge, information, and belief, and I so indicate by signing below. I understand that by signing this
form, I agree to allow the Columbia County Sheriff’s Office to conduct a criminal history and administration check as part
of this application process.
_____________________________________________________________ _________________________________
Retiree Signature
Current as of 10-27-15
Date
RETURN COMPLETED FORM TO:
Columbia County Sheriff’s Office
Attention: Training
2273 County Camp Road
Post Office Box 310
Appling, GA 30802
Subscribed and sworn to before me:
Notary Public _____________________________
This ________ day of ______________ 20___
My Commission Expires _________________
LEOSA APPLCIATION CONTINUATION FORM
Name:____________________________________________________________________________________
Last
Current as of 10-27-15
First
Middle