Johnny cyber law member 209

CYBERLAWENFORCEMENT.ORG MEMBER APPLICATION FORM (See Instructions & Purpose and Use Statement on Back) Application Date_________________ Applicant Information Please Type or Print Clearly (All Information Must Be Completed) Name (Last, First, Middle Initial)_____________________________________________________________________________________________ Agency/Organization______________________________________________________________________Active____________Retired_________ Rank & Duty Position______________________________________________________________________________________________________ Duty Address______________________________________________________________Duty Telephone No.______________________________ City/State/Zip Code/Country________________________________________________________________________________________________ Home Address_____________________________________________________________Home Telephone No._____________________________ City/State/Zip Code/Country________________________________________________________________________________________________ Date of Birth_______________________________Sex___________________________________________________________________________ Primary Email Address_____________________________________________________________________________________________________ Alternate Email Address____________________________________________________________________________________________________ Warning Membership in Cyberlawenforcement.Org (CLEO) is reserved for authorized members of the law enforcement/criminal justice community in addition to certain security level and legal experts. Information presented by this organization is considered sensitive but not classified and is for official law enforcement/criminal justice use only. The online access to this organization will be monitored for security and administration of purposes and accessing this organization’s system constitutes consent to monitoring. Any unauthorized access or unauthorized use of the information gained through this organization by authorized users or others is prohibited. Certification (Please mark appropriate eligibility box and complete appropriate signature lines) 0 Active/Retired Employee of Law Enforcement Agency I hereby certify that I am an active or retired employee of the duly constituted law enforcement agency described above in this application and that I understand and consent to the terms of this application, including the provisions set out in the above Warning and the Purpose and Use Statement on the reverse, and agree to abide by all such provisions. Signed_____________________________________________(Applicant) (In addition to signature below, authorization by Agency Head or Designee on official agency letterhead must be attached) I hereby certify that the above-named individual is an active or retired employee of the duly constituted agency described above and is authorized to become a member of Cyberlawenforcement.Org. Signed_____________________________________________(Agency Head or Designee)_________________________(Title) 0 Employee of Criminal Justice/Legal Agency I hereby certify that I am an employee of the duly constituted criminal justice/legal agency described above in this application and that I understand and consent to the terms of this application, including the provisions set out in the above Warning and the Purpose and Use Statement on the reverse, and agree to abide by all such provisions. Signed_____________________________________________(Applicant) (In addition to signature below, authorization by Agency Head or Designee on official agency letterhead must be attached) I hereby certify that the above-named individual is an employee of the duly constituted agency described above and is authorized to become a member of Cyberlawenforcement.Org. Signed_____________________________________________(Agency Head or Designee)_________________________(Title) Background Please tell us about your background, experience and special qualifications (include date you joined your agency, any special training you have attended, personal interests and goals. If applying for Legal Team, please include a copy of your Credentials to practice law. ________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. Purpose and Use Statement Purpose and Use – The principle purposes of CLEO membership forms are to collect personal information needed to determine if you qualify as an