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HomeMy WebLinkAboutVoegel, Christian W, Jr OATH OF OFFICE FOR FIRE POLICE RECEIVED STATE OF NEW YORK OCT 2 3 2019 COUNTY OF SUFFOLK Southold Torn Clerk 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 Cu4bo e FIRE DEPARTMENT/COMPANY, ACCORDING TO THE BEST OF MY ABILITY. CA,��- ti/ ' zr,- SIGNATURE 2(00 New sla%k Loj ADDRESS to (L)k6yvii NYo l 64- CITY/STATE/ZIP 4-CITY/STATE/ZIP SUBSCRIBED AND SWORN BEFORE ME THIS I2 DAY OF OCT�BE& 20 19 LAWRENCE MICHAEL ZACARESE TARY PUBLIC Notary Public,State of w Vo* Qualified in Suffolk County Commission Expires March 28.20! RECEIVED New York State Division of Criminal Justice Services PEACE OFFICER REGISTRY ENTRY FORM -CERTIFICATION OF INITIAL EMPLOYMW 2 3 2019 (Executive Law§845-a) SECTION I—REGISTRANT INFORMATION To be completed b the re Istrant Southold Town Cler_k.fk Last Name11 FNName 1 MI Date f Birth G�f Social Security Number 42. �l ��. 1,�R651a,, d� 26 ��9 F Q 7 0 8'F' Q 9 15" Home Residence Mailing Address City,State,Zip County Rf orae Residence 335$5 ma;n �aad C�'tGho ye �� �, 3� S ut ( Home Residence Street Address(if Different) City,State,Z City,State,Country of birth(if other than U S) I am the person named above. I understand that the information in Section I 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 belief. SignC/qt % Dated//z / S E C T 10 N 11—AGENCY INFORMATION To be completed by the chief law enforcement officer Last Name First Name MI Title of Person Signing Section 11 S�/Akve ` s L c 1,L42j. Name of Law Enforcemeldt Agency Telephone Address City,State,ZIP 26 S� 6 I V C L�T CLaq L4 icy r t.3 CPL§2.10 Subdivision CPL TltlelPosition of Registrant Weapo cator(Circle All That Apply) NON 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 Por 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 Il 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 belief 1,uaderstand I am respeqsib1e,4br providing the registrant with the requisite training pursuant to CPL§2 30 Signature Date S E C T 10 N 1 I I—CIVIL SERVICE INFORMATION o 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 Perso�en�cy Telephone Address City,State, Title and Civil Service Classification of the Registrant I am the civil service officer responsible for c g the appointment of individuals appearing on the payroll of the law en ent agency named in Section 11. 1 understand that the information in Section 111 is a written statement that will be presented to the Division of Criminal Justice Services for rid 1 certify that it is true to the best of my knowledge and belie :7� Date S E C T 10 N I V—OATH OF OFFICE Public Officers Only-To be completed by the re istrar resporisible for recording oaths of office Last Name First Name / M�I� Title of Person Signing Section IV � /Y 7-,q, 7 (J �1 S%SIG f IcsL� Name of Recording Office (-d 'r? &6- DISTe �ne /3 �® Address City,State,ZIP Gtr 7cI4-v A t 11935 1 am the officer responsible for recording the oaths of office of individuals appointed as peace officers of the law enforcement agency named in Section Il 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 1 understand that the Information in Section IV 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 `ielref 3i Date O7tAdmIistered 2 1 r COPYRIGHT©2007 NEW YORK STATE DIVISION OF CRIMINAL JUSTICE SERVICES(JAN 2007) »3116o