Transcription of ARIZONA DEPARTMENT OF PUBLIC SAFETY APPLICATION …
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DPS 802-07213 Rev. 4-27-2020 ARIZONA DEPARTMENT OF PUBLIC SAFETY APPLICATION FOR LAW enforcement OFFICERS SAFETY ACT (LEOSA) CERTIFICATE OF FIREARMS PROFICIENCY NOTE: This certification is valid for ARIZONA residents only (USC Title 18, Chapter 44, Section 926C(d)2(B)). Resident is defined under ARS 28-2001. TYPE OR PRINT LEGIBLY USE CAPITAL LETTERS USE BLACK INK ONLY Please read the instructions on page two of this APPLICATION . INITIAL RENEWALAPPLICANT INFORMATION LEGAL NAME (Last, First, Middle) RESIDENCE ADDRESS (Street # and name including apartment / Lot #) CITY STATE ZIP CODE MAILING ADDRESS (If different from above) CITY STATE ZIP CODE SSN (Optional) CONTACT PHONE NUMBER ORIGIN/RACE GENDER HEIGHT WEIGHT EYE COLOR HAIR COLOR DATE OF BIRTH PLACE OF BIRTH FORMER LAW enforcement AGENCY INFORMATION (TO BE COMPLETED BY APPLICANT) AGENCY NAME: CITY & STATE TRAINING INFORMATION (TO BE COMPLETED BY INSTRUCTOR) AZ POST CERTIFIED, DPS RECOGNIZED LEOSA INSTRUCTOR NUMBER NRA INSTRUCTOR NUMBER PRINT NAME OF INSTRUCTOR JUDGMENTAL ASSESSMENT S
ARIZONA DEPARTMENT OF PUBLIC SAFETY . APPLICATION FOR LAW ENFORCEMENT OFFICERS’ SAFETY ACT (LEOSA) CERTIFICATE OF FIREARMS PROFICIENCY . NOTE: This certification is valid for . Arizona residents only (USC Title 18, Chapter 44, Section 926C(d)2(B)). Resident is defined under ARS §28-2001.
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