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Form AD-1 PAR
R-03/2011
STATE OF NEVADA
COMMISSION ON PEACE OFFICERS’ STANDARDS AND TRAINING
Records and Certification Section
5587 Wa Pai Shone Avenue
Carson City, Nevada 89701
(775) 687-7678*Fax (775) 687-4911
PERSONNEL ACTION REPORT
Pursuant to NAC 289.350 and 289.360
SECTION “A” CLASSIFICATION
APPLICANT IS
NEW EMPLOYEE
Complete Sections A, B, D, E
TERMINATED EMPLOYEE
Complete Sections A, B, C, E
A NAME CHANGE EMPLOYEE
Complete Sections A, B, E
RECORDS UPDATE
Complete Sections A, B, D, E
The applicant is CURRENTLY a Nevada POST CERTIFIED Peace Officer.
Yes
No
The applicant is CURRENTLY a US citizen.
Yes
No
The applicant is CURRENTLY 21 years of age or older.
Yes
No
The applicant meets all requirements of NAC 289.110 (Standards of Appointment).
Yes
No
Pursuant to NAC 289.110 (1)(a) thorough Background Investigation Completed. (New Employees Only)
Yes
No
Name of Background Investigator (please print)
Agency Completing Background Investigation
Phone
Reserve
Line
Supervision
Management
Executive
CATEGORY I
CATEGORY II
CATEGORY III
RESERVE LIMITED
SECTION “B” EMPLOYEE INFORMATION
Social Security Number DOB POST ID#
Current Name
Male
Female Ethnic Origin
Last First Middle
Previous Name
Last First Middle
Residence Address
Street City State Zip
Current Agency Information
Agency Name Hire Date
(As A Peace Officer)
Street Address City State Zip
Agency Type
Police
Corrections / Detention
Parole / Probation
Tribal
Other – Please Specify:
SECTION “C” TERMINATED EMPLOYEES
Terminated Employees includes those who transfer into non-sworn positions within the agency.
Type of Action
Resigned
Discharged
Retired
Deceased
Other
Effective Date of Termination
If DISCHARGED, was criminal activity involved which would be cause for suspension or revocation of the
Certification pursuant to NAC 289.290?
Yes
No
Recommendations: As a result of this termination, you as the agency administrator, make the following recommendation
No Action
Suspension
Revocation
If “Suspension” or “Revocation” is recommended, supporting documentation MUST accompany this Personnel Action Report
substantiating any criminal charges, to include the jurisdiction in which criminal charges were initiated.