• Application for 911 Telecommunicator Certification Course

  • Do not submit this application unless a "New Hire -- Telecommunicator Form" has been submitted by your agency. Applications submitted without a prior submittal of the new hire form will result in a rejection of the application.

  • The following questions are used to determine your suitability for 911 telecommunicator employment and certification in the State of South Dakota. You are responsible for providing complete, accurate and truthful responses to all questions asked in this document. You MUST fully answer each question. Failure to disclose all the required information may result in denial of your application. Information reported in this application will be subject to verification by Law Enforcement Training and/or the appointing agency.
  • Name (First Middle Last, Suffix)
  • Alias(es), Nicknames, Maiden Name(s), Other Changes in Name
  • Alias(es), Nicknames, Maiden Name(s), Other Changes in Name (2)
  • Home Address
  • Education

  • Personal History

  • Have you ever had your drivers license, in any state suspended or revoked?
  • Telecommunicator Discipline History

  • Excluding the telecommunicator position related to this application, have you ever been employed as a telecommunicator?
  • Have you ever had your 911 Telecommunicator certification suspended, revoked, or voluntarily surrendered in
    South Dakota or any other state?
  • Have you ever been dismissed from a telecommunicator certification course, employment or training in South Dakota or any other state?
  • Have you ever been discharged for cause from employment as a telecommunicator or have resigned as a telecommunicator in lieu of termination?
  • Drug Usage History

  • Have you unlawfully used any prescribed drug, controlled substance, or marijuana within in the past 365 days? Pursuant to Administrative Rule 2:05:03:09 (5), the use or possession of marijuana or any marijuana derivative is deemed unlawful regardless of whether such use or possession may be legal under state law or pursuant to a valid prescription.
  • Professional Licenses

  • Have you ever voluntarily surrendered any professional/occupational certification or license or have you ever had any professional / occupation certification or license suspended or revoked?
  • Criminal History

  • Have you ever been cited, arrested, and/or otherwise charged with a criminal offense? This includes all juvenile offenses, traffic citations, criminal citations/summons and arrests for ordinance violations, misdemeanor, or felony crimes by any city, county, state, tribal, federal, or military law enforcement agency. Be advised that pursuant to South Dakota Codified Law § 23-3-42 and not withstanding any legal advice you may have received to the contrary, you MUST list any suspended impositions or suspended executions of sentence. Failure to disclose all the required information may result in denial of your application.
  • Military Service

  • Employment -- Last 5 Years

  • Employer #1
  • Employer #2
  • Employer #3
  • Employer #4
  • Employer #5
  • References (List 3 non-relatives or employers) -- Name, Address, Phone #, & Occupation
  • I certify that there are no misrepresentations, omissions, or falsifications in the foregoing statements and answers, and that the entries made by me above are true, complete, and correct to the best of my knowledge and belief and are made in good faith.

    I further agree and consent in advance to being summarily discharged without cause or hearing if any of the above information contains any misrepresentations of falsification or if any material information has been omitted.
  • In addition to this application, your agency is required to submit the following documentation on your behalf:

    • Fingerprint Cards (2)
    • Signed Physical Examination Form
    • Signed Release of Information Form
    • DD Form 214 (Member 4 Copy) or Discharge Letter with Classification of Discharge -- if prior military
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