Exhibit_C-_Licensee_Medical_Condition_L2.pdf

FS 02.001 Licensee Medical Condition Declaration 5.31.2017 Page 1 of 1

LICENSEE MEDICAL CONDITION DECLARATION (L-2) Commission Rule §217.1, 217.7

INDIVIDUAL INFORMATION

1. TCOLE PID 2. Last Name 3. F i rs t Name 4. M. I . 5 . Suf f i x (J r . , e tc . )

6. Home Mailing Address 7. City 8. State 9. Zip Code

APPOINTMENT (Do not check if student is in an academy)

10. Initial Appointment, Never Licensed License holder with more than a 180 day break in service

11. Peace Officer Reserve Officer County Jailer Telecommunicator

DEPARTMENT / ACADEMY INFORMATION

An agency hiring a person for whom a license is sought shall select the examining physician. The hiring agency shall maintain a copy of the report on file in a format readily accessible to the commission.

12. TCOLE Number 13. Appo in t ing Agency o r Academy

Attention Examining Professional: The above information must be completed by the requesting agency prior to the examining professional completing and signing the L-2 form.

INITIAL APPOINTMENTS: Peace Officer (both exams), County Jailer (both exams), Telecommunicator (drug screen only).

MORE THAN 180 day break in service: Peace Officer, County Jailer, and Telecommunicator: Drug Screen ONLY.

I certify that I have completed my examination of the examinee, on this date and determine the examinee is found:

MEDICAL EXAM - To be physically sound and free from any defect which may adversely affect the performance of duty appropriate to the type of license sought.

Physician Physician’s Assistant Nurse Practitioner (State License # not required)

14. Name ( t ype or pr i n t ) 15. L icense No

16. Street Address

17. City 18. State 19. Zip Code 20. Phone Number

21. Date of Examination 22. Signature 23. Date

I certify that I have completed my examination of the examinee, on this date and determine the examinee is found:

DRUG SCREEN - To show no trace of drug dependency or illegal drug use after a physical examination, blood test or other medical test.

Physician Physician’s Assistant Nurse Practitioner (State License # not required) DoT Provider

24. Name ( t ype or pr i n t ) 25. L icense No

26. Street Address

27. City 28. State 29. Zip Code 30. Phone Number

31. Date of Examination 32. Signature 33. Date

THIS DECLARATION IS NOT PUBLIC INFORMATION PER TEXAS OCCUPATIONS CODE 1701.306. VALID FOR 180 DAYS FROM GRADUATION DATE OF ACADEMY, IF ACCEPTED BY APPOINTING AGENCY OR VALID FOR 180 DAYS FROM DATE SIGNED UNLESS WITHDRAWN OR INVALIDATED. MUST BE SIGNED BY A LICENSED PHYSICIAN, NURSE PRACTITIONER, or PHYSICIANS ASSISTANT WITH A VALID PHYSICIANS ID, or in the case of a DoT drug screen only, authorized DoT personnel.

TEXAS COMMISSION ON LAW ENFORCEMENT

6330 E. Highway 290, STE. 200, Aust in , Texas 78723-1035

Phone: (512) 936-7700 http://www.tcole.texas.gov

215204 EDINBURG POLICE DEPARTMENT

Exhibi t C