LAW ENFORCEMENT OFFICER CERTIFICATION IDENTIFICATION ... - South Dakota

LAW ENFORCEMENT OFFICER CERTIFICATION IDENTIFICATION CARD

1. Please fill out top portion of form in its entirety. 2. Enclose $10 check payable to Department of Public Safety. 3. Enclose a self-addressed, stamped envelope for mailing ID to applicant. 4. Send this application, $10 check, and envelope to:

SD Law Enforcement Training Criminal Justice Center 1302 E. Hwy 14, Ste. 5 Pierre, SD 57501-8505

This information will be used to produce your SD Law Enforcement Officer Certification ID. The ID will be in effect for two (2) years from date of issuance. Please print.

South Dakota Driver License Number _______________________________________

Social Security Number___________________________________________________

Full Legal Name ________________________________________________________

Street Address/PO Box___________________________City_____________________

State_________Zip________

Birthdate __________________________

( mm / dd / yyyy )

I authorize the use of my South Dakota Driver License photo to produce my ID card.

_______________________________________ ____________________________

Signature

Date

Law Enforcement Training Approval

I authorize the above signed person to obtain an ID card identifying same as a certified South Dakota Law Enforcement Officer.

______________________________________________ Training Administrator's Signature

Issue Date _____________________________

Expiration Date _________________________

Certification # __________________________

_________________________________ Date

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