Southwest Florida Criminal Justice Academy (A Division of Southwest Florida Public Service Academy)

CROSSOVER PROGRAM -CHECKLIST

Conditions of Crossover Program Eligibility:

(1) Be an act ive certified officer in the discipline the officer is moving from

OR

a. Have successfu lly completed a Commission-approved Basic Recruit Training Program AND

b. Passed the State Officer Certification Exam (SOCE) within FOUR Years (for the discipline the officer

is moving from)

(2) All Participants must have taken AND passed the CJBAT exam fo r l aw Enforcement within FOUR years

of the start ing date of the class.

STEPS

1. Officers must submit a letter of intent to the Academy verifying their intention to attend the

program .

a. The letter and their attendance must be approved by their Agency Administration .

b. All participants must meet th e requirements of F.S. 943.13, as ver ifi ed by their agency using the

Fingerprint Notification Respon se Form.

c. The Agency will also need to submit a Course Registration form for each participant.

d. This requ irem ent doe s not obl igate t he Officers' emplo ying agency to pay t he tuition for the

course.

2. If the proposed student is an open enrollment applicant, they must complete the entire open

enrollment process. This includes:

a. Verificati on of passing the l aw Enforcement CJ BAT Exam within th e last 4 years,

b. Comp letion of the open enrollment app lication , and

c. Processing of their fin ger print s for a background check (pr ior to the beginning of th e classes).

3. The courses will be conducted Monday thru Friday of each week.

Based on enrollment numbers, we wi ll be attempting to provide an afternoon class fr om 1pm till

5pm and an evening class from 6pm till 10pm. (Minimum amount for each class w ill have to be 15).

Southwest Florida Criminal [ustice Academy Course Fees:

Crossover Correctio ns to CMS law Enfor cement Academy Fees

In-State $2,180.00

Out of State $6,779 .07

State Exam fee is $125.00

- - -

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Southwest Florida Public Service Academy 4312 E. Michigan Ave. Ft. Myers Fl 33905 Tel: (239) 334 - 3897 - Fax: (239) 334 - 8794

Todd Everly. Director • Robert Martin Ill. Corrections Coordinator • Jack Thomson, Law Enforcemen t Coordinator

Todd Everly Academy Director

Robert Martin III Coordinator Correction s & Crossover LEO- CO

Jack Thomson Coo rdinat or Law Enforcement, Crossove r CO-LEO , &EOT

Office Use Only

FBAT/CJBAT RESULTS : Date Pas sed: / /

M D Y

SCORE:

o Law Enforcement/ o Corrections

Finger Print s Date:

Open Enrollment Application for:

o Crossover - CO to LEO o Crossover - LEO to CO

Name: ____ _____ __ __ _____ _ Social Securit y# _________ Last Name First N:imc i\11.

Date of Birth: ____ / / C urr ent Phone #( ___ -) ______ i\lonth / Day / -Y c-ar-

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3 en

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_ = ;-.., O" ®....,Street Address Apartment#

City Co unt y Sta te Zip

Page 1 of 10 11/8/2016

SOUTHWEST FLORIDA PUBLIC SERVICE ACADEMY PERSONAL HIST ORY QUESTI ONNAIRE

Do you hav e pr evious Law Enforcement Ex perienc e? ( ) Yes ( ) No

I. Na me ___ _____ _ _ __ __ ____________ ______ _ _ __ _

Last Fir st Middl e

Str eet Addr ess Apar tment #

C ity Cou nty Sta te Zi p

~--~-----------~--✓---------~--~>-------Reside nce T elep hone Business Te lep hone Ce ll Te leph one

2. Alias (es) , Nickn a mes, M aide n Na me, or oth er cha nges in yo ur na me. (Att ac h Ma rria ge Cert ifica te, etc)

T h P fn ll n"v in o in fnr m n t inn ic. c;nl ,..lv f n r th ,.. n11r nn~,.. nf rnmn l in n rl' w ith

3. Race / Et hni city (C heck one only)

( ) W hit e, Non- Hispa nic

( ) Blac k, Non- Hispani c

( ) Hispa nic

( ) Asia n or Pacific Isla nd er

( ) Ameri ca n Indi a n o r ___ _________ _

4. Ma le ( ) 5. Date of Birth (Mo nth , Day , Yea r) 6. Place of Birt h (C ity, Co unt y, Sta te)

Female ( )

7. U.S. C itizen: Natu ra lize d Cer ti ficat e Num ber If der ived, pa rent Ce r tificate Num ber

Yes ( )

No ( )

Date , Place and Cour t ___ _________ ________ __________ _

8. Ed uca tion leve l (checking highest leve l atta ined)

( ) High Sc hoo l / GE D ( ) Bac helors ( ) Doctora te

( ) Assoc ia tes ( ) Maste rs

9. Height __ __ _ W eig ht _____ Co lor of Eyes ___ _ _ Co lo r of Ha ir _ _____ _

10. Na me, Relatio nship and Ph one Num ber (s) of pe rson to not ify in case of emer gency: _______ _ _

Page 2 of 10 11/8/2016

11. Marital Status: ( ) Single ( ) Married ( ) Divorced

Name of Spou se: __ ____ ________ _

Contact Number: ______ ________ _

12. Education:

a. List all High Schoo ls attended: (include copies of High School or G.E.D. Diploma)

NAME LOCATION DATES

From

ATTENDED

To

GRADUATED

Yes No

b. Higher education. List informlltion for all Colleges or Universities attended. Include a copy of a ll officia l transcripts from the institution s of higher education that you attended with this application.

NAi\l E AND LOCAT ION OF COLL EGE OR UNIVERSITY

DATES ATTE NDED

FnOi\l TO

CREDIT HOURS

SEi\l ESTER QUA RTER

DEGREE

RECEIVED

YEAR

RECEIVED

c. Other schools or trade, vocationa l, business, or militar y trainin g th a t yo u hav e completed. List the name and location of each school, the date s attended, the subj ects studied, certific a te and any other pertinent data.

FROi\l DATE S

TO NAi\lE OF SCHO OL AND LOCAT ION COU RSES ST UDIED CE RTIFI CATE

Y ES '0

Page 3 of 10 11/8/2016

------- --------

13. Have you ever attended or applied at a Criminal Justice Academy? Yes ( ) No ( )

If yes, where: ____________________________ _

Date: ___________ to ________ _

Reason for leaving/denial: ___________________________ _

14. MILITARY HISTORY

a. Have you ever served in the uniformed armed services of the United States of America? Yes ( ) No ( ) If yes, INCLUDE A COPY OF YOUR DD 214 with your application.

If no, PROVIDE SELECTIVE SERVICE NUMBER _________________ _

b. Branch of Service _________ _ Company _________________ _

Regiment ___________ Division __________ Ship_________ _

c. Highest rank held________________________________ _

d. How many periods of active military service have you had? _________________ _

e. What is the type of your discharge? Be exact:

Honorable ( ) Dishonorable ( ) General ( ) Medical ( ) Other ( )

f. Give date and location of entrance to active duty: _____________________ _

g. Give date and location of discharge: _________________________ _

h. Give period or periods of active military service:

To ______ _ From _______ _From To

From ______ _ To From------- -------- To--------

i. Are you now or were you ever on active or inactive duty of any branch of the United States Reserve Forces?

Yes ( ) No ( ) If yes, state which: Active ( ) Inactive ( )

j. Are you now or were you ever a member of the National Guard? Yes ( ) No()

State _______ Regiment __________ Unit ______ Rank ______ _

From ____ _ To ____ _ Type of Dischar ge __________________ _

k. Were you ever court-mart ialed, tried on charges, or were you ever a subject of a summary court, deck court ,

captain 's mast or company puni shment such as an Article 15, or any other disciplinary action while a member

of the armed forces of the United States? Yes ( ) No ( ) If yes, explain below:

15. Emp loyment History : The pa st IO yea rs to C urrent Employment Status. Use th e Notes section to explain why

yo ur employment ended.

F rom Date Name of Employer Part Time Full Time ( ) ( )

,Job Title

To Date Street Address Phone Numb er Descri)ltion of Duties

Salar y Begin Cit3·, S tate , Zi1> Co de Nam e of Sup ervi sor

Salar y End Wh y did yo u le:we? Na me of Co-Worker

Notes:

From Date Name of Employer Part Time Full Tim e ( ) ( )

.Job T itle

To Date Street Addr ess Phone Number Descripti on of Duties

Sala ry Begin City, State, Zip Code Name of Sup ervi sor

Salary End Why did you leave'! Na me o f Co-Worker

Notes:

From Date Name of EmJlloyer Part Time Full Time ( ) ( )

Job Title

To Date Street Addre ss Phone Number Descripti on of Duties

S:1lary Begin City, Stat e, Zip Code Na me o f Supervi sor

Salary End Wh y did yo u leave '? Name of Co-Worker

Page 5 of 10 11/8/2016

Notes:

From Date Name of Employer Part Time Full Time ( ) ( )

Job Tit le

To Date Street Address Phone Number Description of Duties

Sal:1ry Hegin City, State , Zip Code Name of Supervisor

Salary Eud Why d id yo u leave? Name of Co-Worker

Notes:

From Date Name of Employer Part Time Full Time ( ) ( )

Job Ti tle

To Date Street Addre ss Phone Number Description of Duties

Salary Begin City, Sta te, Z ip Code Name of Superv isor

Salary End Why did you lei1ve'! Na me of Co -Wo r ker

Notes :

From Date Name of Employer Par t Time Full Time ( ) ( )

Job Title

To D:lle Street Address Phone Numbe r Description of Duties

Salary Hegin City, State , Zip Co de Name of Supe rvisor

Salar y End W hy did you leave'! Name of Co-\Vo rker

Notes:

Page 6 of 10 11/8/2016

16. VEHICLE OPERATOR'S LICENSE (Drivers, Chauffeur's etc.)

a. Can you operate a motor vehicle Yes ( ) No ( )

Do you now or did you ever possess a valid driver 's license from the state of Florida? Yes ( ) No ( ) Driver ' s license number ____ _____ Date issued _________________ _ Restrictions ________ ________ ____________________ _

b. Was your license ever suspended or revoked? Yes ( ) No ( ) If yes, give reasons, date and length.

c. Date your license was restored: ________ _________ ______ ____ _

d. List history traffic citations you have received : (including parking tickets)

LOCATION (Street , City, State) APPROX. DATE i\'AT URE OF VIOLATION PENALTY OR DISPOSITIO~

17. MOTOR VEHICLE INSURANCE:

a. Do you presently have automobile insurance? Yes ( ) No ( )

If no, give details:------ -------------- -- -- --- ----------

b. If you presently have automobile insurance, list the following information :

NAi\l E OF COi\ lPA NY POLICY NUi\lBER NAi\l E OF AG ENT ADDRESS PHO NE NUi\lB ER

To__ _____ _List the dates of coverage From_______ _

18. DRUG/ALCOHOL USE:

a. Do you currently use alcoholic bevera ges? Yes ( ) No ( )

Page 7 of 10 11/8/2016

If yes, to what degree? -- ---- ------------------------ ------

b. Do you currently use marijuana ? Yes ( ) No ( )

If yes, to what degree? ------------------------------------

c. Have you ever used or experimented with marijuana ? Yes ( ) No ( )

If yes, amount of times and date of last use _________ _ ______ __ _______ __ _

d. Do you currently use non-prescription dru gs such as cocaine, crack, hashish , opiates , ste roids, pills etc? Yes( ) No ( )

If Yes, which dru g(s) amount of times used , and date of last use: ___ ____ __ _____ ____ _

e. Hav e you ever used or experimented with any other non-prescription dru gs? Yes ( ) No ( )

If yes, which drug (s), a mount of tim es used, and date of last use?

19. Criminal Histor y:

Were you ever arr ested when vou were a juvenile? Yes ( ) No ( ) If yes, how many times? ____ _

List each crime yo u were charged with as a ju ven ile even if one a rre st was for multiple charges

Dntc Char ged With? Convi cted? Disposition

*You mu st reveal vo ur juvenile criminnl record for cmplovmcnl ns n cert ified Law Enforcement or Correc tional Officer *

Expla in any Juvenile arrest entries her e: __________________ _______ __ _

Page 8 of 10 11/8/2016

Have you ever been arrested as an adult? Yes ( ) No ( ) If yes, how many times? ____ _

(Note: if you were ever on Probation or had adjudication withheld , yo u wer e arrested)

List each crime you were charged with even if one ar rest was for multiple charges

Onie C harged With ? Co nvicted ? Disposition

Explain any arrest entries here: _____________________________ _

20. CLOSURE:

In admittance to the Southwest Florida Public Service Academy, the above information I ha ve submitted on this application is true to the best of my knowledge. Any misrepresentations, omis sions , or falsifications in my application will be subject for my application being rejected and/or terminated from attending the Academy.

Signature of Applicant

Date

Page 9 of 10 11/8/2016

SOUTHWEST FLORIDA PUBLIC SERVICE ACADEMY CHECK OFF LIST

My application packet includes copies of my: □ Driver's License

□ Florida Vehicle Registration

□ Social Security Card

□ Certified Birth Certificate

□ High School Diploma or GED Certificate □ Higher Education Certificate

□ Military Discharge DD214 □ NIA

Original forms: □ Driving Record History (Clerk of Courts

□ (1) front view Passport photo

only)

□ Disposition(s) of Arrest (Clerk of Courts) o N/A

□ Official College Transcripts (only if cannot supply certificate) □ Official High School Transcripts

□ Physical Assessment Form CJSTC 75, 75A, & 75B

□ Affidavit of Applicant CJSTC 68 (notarized) □ Release of Information CJSTC 58 (notarized)

SWFPSA Residency Application and Affidavit □ FL Resident □ Out of State

I, the applicant, understand if any information from thi s packet including from the list abov e is missing or incomplete the packet will be returned to me for completion.

Pag e 10 of 10 11/8/2016

Candidate's Signature Date

Page 11 of 10 11/8/2016