BILL BLACKWOOD
LAW ENFORCEMENT
MANAGEMENT INSTITUTE
OF
A Member of the
Application for
Admission
Admission
to the
Current employment with a public law enforcement agency in
Texas, in a full-time paid capacity
A minimum of five (5) full-time years paid employment in a
public law enforcement agency in Texas
Review
and decision of Candidate Assessment Coordinator INSTRUCTIONS
FOR COMPLETING THIS APPLICATION: Answer
each question as completely as possible. If necessary, you may attach
additional sheets of paper. It is not necessary to attach copies of
college transcripts, diplomas, birth certificates, commission certificates or
other similar documents. If you have any questions, please call
the Institute at: (936) 294-3481 or (800) 477-9248 Mail
completed applications to: Bill Blackwood Law Enforcement Management Institute of
Texas Attention: LCC Program Coordinator SHSU, Box 2417 Huntsville, Texas 77341‑2417 LAW ENFORCEMENT
MANAGEMENT INSTITUTE OF A Member of the Application for Admission Please type or print legibly Part I – Personal
Information Name: __________________________________________________________________________ Last First MI Preferred First Name: ________________ Social
Security Number: __________
Date of Birth: ________ Agency Name: ____________________________________________________________________ Chief Executive Officer: ____________________________________________________________ Agency Type:
Total Sworn Personnel: _______________ Department
Logistics: ______ Patrol Officers ______ Sergeants
LEMIT USE ONLY LCC
# ____________________________ __________________________________ ______ Captains ______ Other Name: __________________________________________________________________________ Last First MI REQUIRED: Department Mailing Address: _________________________________________________________ City: ______________________________ State: ________ County: ____________ Zip: _________ Agency Telephone Number: (____) ___________________FAX Number: (____)
______________________ Preferred Telephone Number (for daytime
contact): (____) ___________________________ Work
Email address:___________________________@________________________________________ OPTIONAL: Home Mailing Address: _____________________________________________________________ City: ______________________________ State: ________ County: ____________ Zip: _________ Home
email address: _____________________________@______________________________________ Part II
– Work Experience Do you
currently hold a commission with the Texas Commission on Law Enforcement
Officer Standards and Education or from a law enforcement licensing agency from
another state? __Yes__No If no, are you certified in any other
state? __Yes__No
List state: _________________________ Are you
a licensed peace officer? __Yes__No Summarize your experience as a paid full‑time member of a law
enforcement agency in the following chart. Work category Years experience Operations level First line supervisor Mid manager Commander/Assistant CEO Chief Executive Officer TOTAL Name: __________________________________________________________________________ Last First MI WORK EXPERIENCE CONTINUED: Check the category that best describes your current job
responsibilities. Check one Current
work category
Description Mid manager Supervisor of other
supervisors in a single functional area
Currently and during attendance of each module candidate
must be assigned in a mid-management command or administrative position with a
minimum of two years in that capacityA fully completed application
Attend and
Participate in the Program Overview assigned to
BILL BLACKWOOD
Ethnicity:
African American Native American
Hispanic Asian White
OtherGender: Male Female PID#:_________
Rank/Title: (Chief, Capt., Lt., etc.): _____________________
Municipal
Police Department Sheriff's
OfficeConstable's
Office College/University
PoliceSpecial
District (airport, park, metro, etc.) State Law Enforcement Out of
State Law EnforcementFederal Law Enforcement International
Law Enforcement
______ Lieutenants