Free 46177.FH11 - Indiana

ANNUAL REPORT ON TRAINING STATUS
State Form 46177 (R2 / 9-07) LAW ENFORCEMENT TRAINING BOARD

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* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.

INSTRUCTIONS: Please type or print clearly. DO NOT FAX THIS FORM.
Last name Maiden / other legal names Date of hire (month, day, year) Employment status of officer (check one) First name Social Security Number * Name of department Middle name Date of birth (month, day, year) Sex Jr / Sr

Male
IDACS / ORI number

Female

Reason for officers separation from the department (check one)

Full-time

Part-time

Reserve

Retired

Deceased

Resigned

Discharged

Leave

This paid officer did not complete the sixteen (16) hour minimum in-service training requirement for calendar year ____________. Reason: _______________________________________________________________________________________________________________ This reserve officer has attended the LETB pre-basic course and has successfully completed all testing, including the firearms qualification course.

Complete this section using the Roster - Law Enforcement Training and Completion of Training Certificate forms from the training provider or instructor. Between January 01 and March 15 of each year, one copy of this completed form for each officer must be sent to the following address: Executive Director, Law Enforcement Training Board, PO Box 313, Plainfield, IN 46168-0313. Only legible, first generation copies will be accepted. TRAINING START DATE
(month, day, year)

TRAINING END DATE
(month, day, year)

LETB TRAINING PROVIDER / INSTRUCTOR NUMBER

IN-SERVICE CREDIT
(hours)

TOTAL NUMBER OF HOURS SUCCESSFULLY COMPLETED
Prepared by (type or print name) Date prepared (month, day, year) Prepared for year

0

COMMENTS BY REPORTING AGENCY

FOR LETB USE ONLY