12 NCAC 09I .0109           CERTIFICATION FORMS – ADULT CORRECTION

The following Commission-approved forms shall be used during the application process for correctional officer or probation/parole officer certification:

(1)           Form F-5A (DAC), Adult Correction Report of Appointment and Application, shall include the following information about the applicant:

(a)           type of certification applying for;

(b)           name, social security number, previous names used, date of birth, home address, phone number, driver's license number and issuing state, and email address;

(c)           prior certification history, including whether the applicant previously held a position requiring certification or licensure from any commission, board, or agency and whether any previous certification was suspended or revoked;

(d)           whether the applicant has ever been denied employment for a position with a law enforcement agency, corrections agency, or security agency;

(e)           names and types of relationships with any family member in prison, jail, or on probation or parole;

(f)            history of illegal drug use;

(g)           criminal history information, including offense, type of offense, disposition offense, date of offense and disposition, court docket number, county and state, and probation status for all offenses charged, expunged, and pending;

(h)           explanation of any Domestic Violence Orders, Ex-Parte Domestic Violence Protection Orders, or any other protective orders issued against the applicant;

(i)            military history, including date and type of last discharge, and the branch, type of discharge, and start and end dates of service for all periods of active duty;

(j)            explanation for any type of military discharge other than honorable;

(k)           report of appointment information to be completed by the agency authorized representative, including: applicant's position title, Beacon number, effective date, education and degree information, date of fingerprinting, date Division of Criminal Information Network (DCIN) checks completed, date psychology screening conducted, name and license number of psychologist, date of negative drug test and name of lab, whether Forms F-1 and F-2 were completed (pursuant to .0105 of this Subchapter), date of physical exam, name and license number of examining medical practitioner;

(l)            notarized signature of the applicant; and

(m)          signature of agency authorized representative.

(2)           Form F-5C (DAC), Report of Reappointment/Reinstatement of Certification, shall include the following information about the applicant:

(a)           type of certification applying for;

(b)           type of application (transfer from a non-certified position or reappointment following separation);

(c)           name, social security number, previous names used, date of birth, home address, phone number, driver's license number and issuing state, and email address;

(d)           criminal history information, including offense, type of offense, disposition offense, date of offense and disposition, court docket number, county and state, and probation status for all offenses charged, expunged, and pending;

(e)           explanation of any Domestic Violence Orders, Ex-Parte Domestic Violence Protection Orders, or any other protective orders issued against the applicant;

(f)            report of appointment information to be completed by the agency authorized representative, including: position title and effective date, Beacon number, date of fingerprinting, date DCIN checks completed, date psychology screening conducted, name and license number of psychologist, date of negative drug test and name of lab;

(g)           notarized signature of the applicant; and

(h)           signature of agency authorized representative.

(3)           Form F-5D (DAC), Notice of Certification Transfer, shall include the following information about the applicant:

(a)           name, Beacon number, social security number, date of birth, email address, home address, and phone number;

(b)           current or previous certification type and certification type transferring to;

(c)           position title and effective date of transfer;

(d)           education and experience information;

(e)           notarized signature of the applicant; and

(f)            signature of the agency authorized representative.

(4)           Form F-5E (DAC), Notice of Transfer to a Non-Certified Position, shall include the following information about the transferring officer:

(a)           name, date of birth, and last four of social security number;

(b)           original certification date;

(c)           date of transfer to non-certified position;

(d)           title of non-certified position;

(e)           type of last certification held, including whether it was probationary or general and whether it was correctional officer certification or probation/parole officer certification;

(f)            whether basic training was completed;

(g)           whether the officer has been subject to a disciplinary transfer;

(h)           name, title, and signature of agency head or authorized representative;

(5)           Form F-38 (DAC), Authorization for Release of Information to North Carolina Criminal Justice Education and Training Standards Commission and North Carolina Department of Adult Correction, shall include the following:

(a)           applicant's name, date of birth, driver's license number and issuing state, home address, and phone number; and

(b)           applicant's notarized signature.

History Note:        Authority G.S. 8-50.2; 17C-6;

Eff. October 1, 2026.