HR LEOSA Application Form

HR LEOSA Application Form

Purpose: This application is used by the Human Resources unit to document an employee's or retiree's claim of Law Enforcement Officers Safety Act (LEOSA) eligibility, to obtain authorizations to verify prior law enforcement service, firearms qualification records, and separation status, and to determine whether the applicant meets internal policy requirements for issuance of LEOSA-related credentials. Complete all sections fully and sign the certification at the end.

Personal Information

Date of Birth: Social Security (last 4):

Position Information (If current or most recent employer)

Hire Date: Separation/Retirement Date:

Employment History (Most recent first)

Education & Training

Professional References

LEOSA Eligibility Affirmations

The applicant affirms the following. Check each box that accurately describes your status and attach supporting documentation where indicated.

I retired or separated from service in good standing and was not dismissed for cause.

My separation was honorable or equivalent, as defined by the employing agency.

I have not been convicted of a felony or an offense that would disqualify me from possessing a firearm under federal or applicable state law.

I am not a fugitive from justice and I am not currently subject to any pending indictment or criminal charges that would disqualify me.

I have not been adjudicated mentally incompetent or involuntarily committed in a manner that would prohibit possession of a firearm.

I am not subject to any court order (domestic violence or similar) that prohibits possession of firearms.

I have current firearms qualification documentation or the ability to complete agency-required qualification prior to issuance.

Authorizations, Disclosures and Certification

Authorization to Verify: I authorize the Human Resources unit and its authorized agents to contact any current or former employers, training institutions, law enforcement agencies, licensing authorities, and other persons or organizations to verify any information contained in this application, including records related to employment, separation status, training, and firearms qualification. I authorize the release of records and information necessary to confirm my eligibility under LEOSA and the organization's internal policies.

Background and Records Check Consent: I consent to background checks and record searches as required to determine eligibility. I understand that any adverse information discovered that bears on LEOSA eligibility may result in denial of a LEOSA credential or revocation of any authorization previously issued.

Applicant Certification and Penalties: I certify under penalty of law that the statements made in this application are true, complete and correct to the best of my knowledge. I understand that making a false statement or omission may be grounds for denial, rescission of LEOSA authorization, disciplinary action, or criminal prosecution where applicable. I further release from liability any person, agency or organization that provides information in good faith pursuant to this application.

Retirement/separation paperwork

Current firearms qualification certificate

Government-issued photo identification

Additional Information

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