FORM CC-1430 (MASTER, PAGE ONE OF THREE) 07/18 APPLICATION FOR APPOINTMENT OF Case No. ............................................................ SPECIAL CONSERVATOR OF THE PEACE COMMONWEALTH OF VIRGINIA VA. CODE 247247 19.2-13, 19.2-13.1 ........................................................................................................................................................................ Circuit Court CITY OR COUNTY The undersigned applicant petitions the court to appoint the following individual as a special conservator of the peace and states that appointment of this individual is necessary for the security of property or the peace. ................................................................................................................................................................................................................................................................... (FULL NAME OF PROPOSED SPECIAL CONSERVATOR) FIRST MIDDLE LAST SUFFIX ......................................................................................................................................................................................................................................................... STREET ADDRESS OF PROPOSED SPECIAL CONSERVATOR ......................................................................................................................................................................................................................................................................................................... DEPARTMENT OF CRIMINAL JUSTICE SERVICES NUMBER IDENTIFYING INFORMATION FOR PROPOSED SPECIAL CONSERVATOR RACE SEX BORN HT. WGT. EYES HAIR MO. DAY YR. FT. IN. SSN: [ ] The undersigned applicant requests that the court authorize the proposed special conservator of the peace, who is employed by [ ] a state agency, [ ] the Shenandoah Valley Regional Airport Commission, OR [ ] the Richmond Metropolitan Transportation Authority to use the seal of the Commonwealth in a badge or other credential of office for the following reason(s): ................................................................................................................................................................................................................................................................... [ ] The undersigned applicant requests that the court authorize the proposed special conservator who is employed by [ ] the Shenandoah Valley Regional Airport Commission, OR [ ] the Richmond Metropolitan Transportation Authority of the peace to use the title 223police224 on any badge, uniform or vehicle in the performance of his duties for the following reason(s): ................................................................................................................................................................................................................................................................... [ ] The undersigned applicant requests that the court authorize the proposed special conservator of the peace to use red or red and white flashing lights and sirens on the vehicle used by the special conservator of the peace when he is in the performance of his duties for the following reason(s): ................................................................................................................................................................................................................................................................... [ ] The undersigned applicant requests that the court authorize the proposed special conservator of the peace to affect arrests, using up to the same amount of force as would be allowed to a law-enforcement officer employed by the Commonwealth or any of its political subdivisions when making a lawful arrest. Explain necessity for the security of property or the peace in the space provided below. ...................................................................................................................................................................................................................................................................... American LegalNet, Inc. www.FormsWorkFlow.com FORM CC-1430 (MASTER, PAGE TWO OF THREE) 07/18 List the duties the proposed special conservator of the peace is qualified to perform based on having successfully completed the training as established by the Criminal Justices Services Board in the space provided below. ...................................................................................................................................................................................................................................................................... Explain the geographical limitations of proposed special conservator222s authority in the space provided below and include the address and description of specific real property. Include explanation of necessity if any of the identified properties are outside the city or county where this application is made. If the proposed special conservator of the peace is an employee of the Shenandoah Valley Regional Airport Commission or the Richmond Metropolitan Transportation Authority, identify any additional jurisdictions in which the proposed special conservator of the peace may exercise his duties. ...................................................................................................................................................................................................................................................................... Indicate the requested length of term for the proposed special conservator, not to exceed four years. ...................................................................................................................................................................................................................................................................... [ ] Check here if requesting court authorization for the special conservator of the peace to have the authority to make an arrest outside of the specified geographical limitations if the arrest results from a close pursuit that was initiated when the special conservator of the peace was within the confines of the area wherein he is to be authorized to have the powers and authority of a special conservator of the peace. Attach the following documents: (1) temporary registration letter issued by the Department of Criminal Justice Services, (2) results of the background investigation conducted pursuant to Va. Code 247 19.2-13(C), (3) evidence establishing that the proposed special conservator of the peace is covered by a policy of liability insurance or self-insurance in an amount and with coverage as fixed by the Criminal Justice Services Board. If applicant is an official or employee of a school board or county, city or town, its departments or its agents, attach a written assessment from the chief law-enforcement officer of the locality stating the need for the appointment and recommending any limitations that should be included in the order of appointment. .......................................................................... DATE SIGNATURE OF APPLICANT PRINT FULL NAME OF APPLICANT [ ] SHERIFF OF .................................................................................................. [ ] CHIEF OF POLICE OF ................................................................................ [ ] REPRESENTATIVE OF ............................................................................... ................................................................................................................................ NAME AND ADDRESS OF CORPORATION AUTHORIZED TO DO BUSINESS IN COMMONWEALTH [ ] REPRESENTATIVE OF ............................................................................... ................................................................................................................................ NAME AND ADDRESS OF MUSEUM OWNED AND MANAGED BY COMMONWEALTH [ ] OWNER, PROPRIETOR OR AUTHORIZED CUS