Minnesota Board



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REQUEST FOR PEACE OFFICER LICENSE

Please read the data practices advisory on the back of this form before submitting. Completed application and $90 non-refundable licensing fee must be received by the POST Board prior to performing the functions of a peace officer. DO NOT FAX.

Applicant’s Name (Last, First, Middle) Date of Appointment

Date of Birth Gender Social Security Number Appointed as CLEO

Male Female Yes No

Agency Name Applicant’s Email

To be completed by the Chief Law Enforcement Officer

This applicant was appointed under Minn. Stat. 626.84, and has complied with the required POST Board minimum selection standards of Minn. R. 6700.0700.

This applicant has met the following selection standards, the completion of full initial use of force training as required by Minn. Stat.626.8452, subd.2, and that this agency is maintaining documentation to corroborate compliance:

1. Background Investigation 4. Test of Physical Strength and Agility2

2. Fingerprints Sent to BCA and FBI 5. Oral Interview

3. Medical Examination1 6. Psychological Examination3

1. The medical and psychological examinations and use of force training completed during the applicant’s Professional Peace Officer Education Program shall not be considered as satisfying minimum selection standards.

2. Successful completion of the Professional Peace Officer Education may be considered to meet the requirements for a test of physical strength and agility at the discretion of the agency.

3. Name of Licensed Psychologist ______________________________ Recommended for hire: Yes No

Print Chief Law Enforcement Officer’s Name Title Date

Chief Law Enforcement Officer’s Signature Phone

( )

To be completed by the Applicant I affirm:

• I have successfully passed all examinations which are required for licensing and am currently eligible for a peace officer license:

• I am a citizen of the United States;

• I possess a valid driver’s license;

• I have never been convicted of a felony as defined in Minn. R. 6700.0100, subp. 12a, in this or in any other state; and

• I have submitted a comprehensive employment application for this position.

Subscribed and sworn to before me this __________day

______________________________

of _________________________________, 20_______. Date of Request

_____________________________________________ ____________________________________________

Notary’s Signature Applicant’s Signature (08/17)

Use of Data Collected by the POST Board on This Application Form

This application is used to assist the POST Board in determining your eligibility to be issued a peace officer license.

Application data on licensees is classified as public data under Minn. Stat. 13.41, subd. 5. That includes application data on licensees, license number, license status, and continuing education records.

While your licensure application, once you have been granted a license, is considered public data, certain information on that form is still classified as private data. That information is as follows:

1. Your social security number, which is protected by federal law and Minn. Stat. 13.355;

2. Your home address, which is classified as private data under Minn. Stat. 13.41, subd. 3; and

3. the name of the state agency, statewide system, or political subdivision that employs you as a licensed peace officer, which is classified as private data under Minn. Stat.13.41, subd. 3.

That private data will not be released except to you, employees of the POST Board whose duties recently require access to that data, those authorized by state or federal law to have access to the data, or those to whom you provide written informed consent authorizing disclosure.

You are not legally required to provide any of the requested information; however, if you do not do so, we will be unable to process your application or determine your eligibility to be issued a peace officer license.

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MINNESOTA BOARD OF

PEACE OFFICER STANDARDS AND TRAINING

1600 UNIVERSITY AVENUE, SUITE 200

SAINT PAUL, MINNESOTA 55104-3825

TEL: (651) 643-3060

FAX: (651) 643-3072

post.state.mn.us

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