L.E.O.S.A. Retired Officer

L.E.O.S.A. Retired Officer
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

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Zip Code
Phone Number*
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Alternative Phone Number
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E-mail Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Retirement Information
Retiring Agency*
Retirement Date*

MonthDayYear
Date
Years of Service*
Agreement
State of Florida, in and for Broward County before me, the undersigned personally appeared {name15} , who being by me duly sworn, deposes and says:
Please check as acknowledging the following that apply
I retired in good standing from law enforcement with: at least 10 years of aggregate service as a law enforcement or correctional officer OR a service connected disability other than mental instability.*

Acknowledge and Agree
I have a non-forfeitable right to benefits under the retirement plan set forth by my agency.*

Acknowledge and Agree
I am not prohibited under Federal law from receiving or possessing a firearm.*

Acknowledge and Agree
I am not under the influence of alcohol or any other intoxicating or hallucinatory substance.*

Acknowledge and Agree
I have no physical limitations that would interfere with the proper handling of a handgun.*

Acknowledge and Agree
I understand that I must meet and follow the procedures established by the L.E.O.S.A. and the State of Florida in meeting the requirements for obtaining proper certification.*

Acknowledge and Agree
I have not made any material misrepresentation, or failed to disclose any material fact, in my request for certification to carry a firearm under the procedures and requirements set forth by the L.E.O.S.A. and the State of Florida.*

Acknowledge and Agree
By typing and signing my name in the space below I certify this information to be true, accurate and complete.*

First NameLast Name
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L.E.O.S.A. Retired Officer

Retirement Information

Agreement

Please check as acknowledging the following that apply