HR LEOSA Waiver Form

HR LEOSA Waiver Form

Personal Information

Position Information

Employment History (most recent first)

Education

References

LEOSA Eligibility and Service History

I certify under penalty of perjury that I served as a sworn law enforcement officer and that the information below is accurate and complete. Agency of employment during service:

Rank/Title at separation: Badge/ID number:

Dates of service: From to Separation status:

I attest that my separation from law enforcement service was not for cause involving moral turpitude, misconduct, or a revocation of firearms authority: Yes

Firearms Training and Proficiency

I confirm I have successfully completed firearms qualification and maintain proficiency. Most recent qualification date:

Medical, Psychological, and Background Checks

I authorize the employer to obtain medical and psychological assessments, criminal history records, and to conduct fingerprinting as necessary to evaluate my eligibility for LEOSA privileges. I understand such checks may include state and national databases and law enforcement records. I hereby consent: Yes

I represent that I am not prohibited by any federal, state, or local law from possessing or carrying a firearm. I agree to promptly report any change in this status or any criminal charge that would affect my eligibility: Yes

Waiver, Release, and Indemnification

In consideration of the employer's review of my application to exercise privileges under the Law Enforcement Officers Safety Act (LEOSA), I RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE the employer, its elected officials, officers, employees, agents, successors, and assigns from any and all liability, claims, demands, causes of action, or losses of any nature arising out of or related to the employer's decision to permit, restrict, revoke, or otherwise administer LEOSA-related privileges, including but not limited to claims for personal injury, property damage, or civil liability resulting from my possession or use of a firearm while exercising such privileges.

I further agree to INDEMNIFY AND HOLD HARMLESS the employer for any third-party claims, suits, or expenses (including reasonable attorneys' fees) arising out of my actions or omissions while carrying or using a firearm under LEOSA privileges, except to the extent such claims are the direct result of the employer's gross negligence or willful misconduct.

I acknowledge that the employer makes no warranty or guarantee of immunity from criminal or civil liability arising from my conduct while carrying a firearm and that the employer may, in its sole discretion, revoke any authorization at any time.

Policy Acknowledgment and Conditions

I acknowledge receipt of the employer's firearm safety and conduct policies applicable to LEOSA privileges. I agree to comply with all employer policies, including requirements for safe storage, reporting of incidents, notification of changes in eligibility, and restrictions on carrying when acting in an official capacity. I understand violations of policy may result in disciplinary action up to and including termination.

Applicant Certifications

I certify that all information provided in this form and any attachments is true, complete, and correct to the best of my knowledge. I understand that false statements or material omissions are grounds for denial of LEOSA privileges and may subject me to disciplinary action.

I authorize the employer and its agents to contact previous employers, training instructors, and references to verify information provided herein and to inquire into any matters relevant to my application for LEOSA privileges.

HR Review (For HR Use Only)

HR Determination: Approved Denied

Acknowledgment and Signature

By signing below I acknowledge that I have read and understand this HR LEOSA Waiver Form, that I consent to the stated releases and authorizations, and that my signature is my affirmative certification of the statements contained herein.

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