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HomeMy WebLinkAboutBehr, Lawrence OATH OF OFFICE FOR FIRE POLICE RECEIVED STATE OF NEW YORK OCT 2 3 2019 COUNTY OF SUFFOLK Southold Town Clerk 1, Lh/Adn Cc- , 1yK DO SOLEMNLY SWEAR THAT I WILL SUPPORT THE CONSTITUTION OF THE UNITED STATES, AND THE CONSTITUTION OF THE STATE OF NEW YORK,AND THAT I WILL FAITHFULLY DISCHARGE THE DUTIES OF FIRE POLICEMAN OF THE C,76110.6,, &— FIRE DEPARTMENT/COMPANY, ACCORDING TO THE BEST OF MY ABILITY. SIGNATURE PzP x- 317 ADDRESS Com:C iv, % //93�' CITY/STATE/ZIP SUBSCRIBED AND SWORN BEFORE ME THIS I,"' DAY OF- OaN M 20 LAWRENCE MICHAEL ZACARESE rARY PUBLIC Nom Public, St�3 of 3�w York Qualified in Suffolk County Commission Expires March 2E,2� RECEIVED New York State Division of Criminal Justice Services OCT 2 3 2019 PEACE OFFICER REGISTRY ENTRY FORM -CERTIFICATION OF INITIAL EMPLOYMENT (Executive Law§845-a) Southold Town Clerk S E C T 10 N I—REGISTRANT INFORMATION To be completed by the registrant) Last Name First NameDate of Birth Ge er Social Security Number Reif4 hlrMI cc, 7->„ `t3 F //I Home Residence Mailing Address City,State,Zip County of Home Residence ® s® 7)7 el± k e- /0' / ?3.s- Hjome Residence Street Address(if Different) City,State,Zip U. City,State,Country of birth(if other than S J ) JCS e- Ct.C �OMl l (' /am the person n med above. /understand that the information in Section/i part of a written statement that will be presented to the Division of Criminal Justice Services for filing,and I certify that it is true to the best of my knowledge and belief Signature Date '&�z I /& - S E C T 10 N I I—AGENCY INFORMATION To be completed by the chief law enforcement officer Last Name First NameMI Title of Pers o Signing Section II Name of Law Enforcemen Agency Telephone CL., I, CP— �� 7 e i 63 a -�3�- 6C/o r� Address // � ( rr J� r _i City,State,ZIP i Z Lo Int tiW S ' f Ea( VI I�Cl C t-c (Cl U F !fl,' Y l I S S— CPL§2 10 Subdivision CPL Title/Position of Registrant Weapons for(Circle All That Apply) NONE FIREARMS ASR BATON Type of Appointment Background Check Conducted Residency Verified Fingerprints submitted to DCJS Full-time Part-time Yes No Yes No Yes No I am the chief law enforcement officer responsible for appointing the person named in Section I as a peace officer of the above named law enforcement agency I understand that the information in Section 11 is part of a written statement that will be presented to the Division of Criminal Justice Services for filing,and I certify that it is true to the best of my knowledge and b understand 1 qM resjLqnsible for providing the registrant with the requisite training pursuant to CPL§2 30 Signature Date S E C T 10 N I I I—CIVIL SERVICE INFORMATION To be completed by the civil service officer for munici al and state registrants) me First Name MI Title of Person Signing Section III Name of Civil Service or Persoency Telephone Address City,State, Title and Civil Service Classification of the Registrant i am the civil serviceofficer responsible for c g the appointment of individuals appearing on the payroll of the law en ent agency named in Section 11 I understand that the information in Section ill is a written statement that will be presented to the Division of Criminal Justice Services for rid i certify that it is true to the best of my knowledge and belie Signature Date SECTION I V—OATH OF OFFICE Public Officers Only-To be completed by the registrar resporisible for recording oaths of office Last Name First Name MI Ttle of Person Signing Section IV Name of Recording Office Telep�ne � 754t— 6” ^_ Addrss State,ZIP 9e6 O /�/b'€► T �t�r GG� CG-(f-7—C404:536 11 s x, S i am the officer responsible for recording the oaths of office of individuals appointed as peace officers of the law enforcement agency named in Section 11 The person named in Section I has filed an oath of office as a peace officer,pursuant to an appointment received from the person named in Section 11 I understand that the information in Section IV i art of a written statement that will be presented to the Division of Criminal Justice Services for filing,and I certify that it is true to the best of my knowledge and 7ehef Dat �Oathgdministere 2-1 f COPYRIGHT©2007 NEW YORK STATE DIVISION OF CRIMINAL JUSTICE SERVICES(JAN 2007) »3116o