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HomeMy WebLinkAboutBoken, Michael C OATH OF OFFICE FOR FIRE POLICE RECEIVED STATE OF NEW YORK OCT 2 3 2019 COUNTY OF SUFFOLK Southold Town Clerk 13&ke.,l 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�z"r- A 05 FIRE DEPARTMENT/COMPANY, ACCORDING TO THE BEST OF MY ABILITY. SIGNATURE Z Ga lc- 1<O�- ADDRESS c��C- �, off ` $- , AJ CITY/STATE/ZIP SUBSCRIBED AND SWORN BEFORE ME THIS r21v DAY OF 00-i-QU& 20 A RY PUBLIC t.AWRENCE MICHAEL ZACARESE Notary Public,State of News York �WO No.02ZA6339303 Qualified in Suffolk County Commission Expires lurch 28,20-19 New York State Division of Criminal Justice Services RECEIVED PEACE OFFICER REGISTRY ENTRY FORM-CERTIFICATION OF INITIAL EMPLOYMENT (Executive Law§845-a) OCT 2 3 2019 S E C T 10 N I—REGISTRANT INFORMATION To be completed by the re istrant Last Name First Name/ MI Date of Birth Gender s fI`�Pte� 80 ke n/ e COY '��(r3'7 C F 070 - (Z • 63 Home Residence eMMailing Address City,State,Zip ✓ County of Home Residence (� 3q L-fkC 3 /J C,--r. , ! I��3J 51'C 0 I & Home Residence Street Address(if Different) City,State,Zip 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 Cnminal Justice Services for filing,and I certify that it is true to the best of my knowledge and belief. Signature Date lit - 17 l�7 S E C T 10 N I I—AGENCY INFORMATION o be completed by the chief law enforcement officer Last Na a FirstNameMI Title of Person Signing Section II Sk/At V P 1/tCt w c<1 cl-L l� Name of Law Enfor(ce ent Agency Telephone C:.t� Lliw tLr, tiIZ �� ; G 656 Address r City,State,ZIPII f (4 3� CPL§2 10 Subdivision CPL Title/Position of Registrant Weapon Gator(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 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 knowled rid behef. I unoe stan 1 am responsible for providing the registrant with the requisite training pursuant to CPL§2 30 Sign at Date S E C T 10 N I I I—CIVIL SERVICE INFORMATION To be completed by the civil service officer for municl al and state registrants) �QAlService First Name MI Title of Person Signing Section III Name or Pers envy 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 I understand that the information in Section Ill is a written statement that will be presented to the Division of Criminal Justice Services fo rid l 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 MI Title of Person Signing Section IV f Name of Recording Office Telephone <:S-1 1) a � !�f s�2C�L �3l- 73i�- W s City,State,ZIP "-p-a c� �� 5v)" Ca k'/-0 4 v, ,/V �l � 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 II 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 wntten 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 9ehef 3ignat a Date Oath A ministe d 1411 z-/ 210 Ir COPYRIGHT©2007 NEW YORK STATE DIVISION OF CRIMINAL JUSTICE SERVICES(JAN 2007) r13/i6o