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HomeMy WebLinkAboutBrewer, Arthur W. OATH OF OFFICE FOR FIRE POLICE RECEIVED STATE OF NEW YORK OCT 2 3 2019 COUNTY OF SUFFOLK Southold Town Clerk I, A k714u Q lj - '--9Acw0< 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 LAIC- 1406'"C. FIRE DEPARTMENT/COMPANY, ACCORDING TO THE BEST OF MY ABILITY. SIGNATURE Mgo 11- YIe /vec,� Q� ADDRESS Gc.�Tc N®(rte& /V, y I1 q3J� CITY/STATE/ZIP SUBSCRIBED AND SWORN BEFORE ME THIS IZ'N DAY OF Oc�224, 20 _ TA RY PUBLIC LAWRENCE MICHAEL ZACARESE Notary Public,State of New York No.02ZA6338303 Qualified in Suffolk County Commission Expires March 28,20-'E RECEIVED New York State Division of Criminal Justice Services PEACE OFFICER REGISTRY ENTRY FORM-CERTIFICATION OF INITIAL EMPLOYMEKLT- 2 3 2019 (Executive Law§845-a) �- Southold Town Clerk S E C T 10 1N��I—REGISTRANT INFORMATION To be completed b the registrant) �q Q b® La me rn1/�� First Name Q�'Jf�°{ d�®(a/��� Ge r Social®/(Security3 bk7 I RRMI M F Home ResidAn 0ence Mailin A dressCity State,Zip County of Home Residence Home Residence Street Address(if Different) City,State,Zip City,State,Country of birth(If other than U S.) S �Mcr- S 4 PIC S /�r►c: 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 riling,and I certify that it is true to the best of my knowledge and belief. q Signature, (,,J , Dat / S E C T 10 N 1 I—AGENCY INFORMATION o be completed by the chief law enforcement officer Last Name i First Name MI Title of Pars pn_Signing Section II 4) LV t' c�.'W3 L c " -, P Name of Law Enforcerjent Agency Telephone j [� Address '/ City,State,pp SLA rr(( � CPL§2.10 Subdivision CPL Title/Position of Registrant Weapon for(Circle All That Apply) NONE FIREARMS ASR BATON Type of Appointment Background Check Conducted Residency Verified Fingerpnnts 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 belief. I u erstand/am responsible for providing the registrant with the requisite training pursuant to CPL§2 30 Signature Date SECTION I I I—CIVIL SERVICE INFORMATION To be completed by the civil service officer for municl al and state registrants) me First Name MI Title of Person Signing Section III Name of Civil Service or Pers ency 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 It. 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 S E C T 10 N I V—OATH OF OFFICE Public Officers Only-To be completed by the registrar resporisible for recording oaths of office Last Name First Name MITitle of Person Signing Section IV Zig /�T7j�i� d� 17rSTy�1G� �-��j Name of Recording Office Telephone am C� C/%CjAl® C1 ���� L S7'e(e—! 4-31 73zlv 467?0 7 Address e �� City,State,ZIP 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 1 understand that the informatron in Section 1V is part of a written statement that will be presented to the Division of Criminal Justice Services for riling,and I certify that it is true to the best of my knowledge and 5elief. ;ignat Date Oath%dmml ered l/ �l COPYRIGHT©2007 NEW YORK STATE DIVISION OF CRIMINAL JUSTICE SERVICES(JAN 2007) r13fi6o