Print Full Name

Officer

Ident. # Print Full Name

Signature

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Date:

o None Manufacturer:

MSA

Model: Millennium Size:

Os

OM

Other:

Filter Model #:

Other:

Filter Expiration Date:

OL

Filter Model #:

Condition of Mask*:

Filter Expiration Date:

PLEASE NOTE IF: *Face shield yellowing, or separating from the mask, condition of head straps, any missing, torn, damaged pieces/parts, etc.

Gun Belt, Belt Buckle, Belt Keepers, Holster, Ammunition Pouch, Handcuff Pouch, CS/OC Holster, Baton/Flashlight Holder Chemical Protective Suite "PPE Kit" Helmet Handcuffs and Key CS/OC Repellent *Check Ex iration Date on canister Authorized Baton Flashlight Radio/Radio Holder/External Microphone Issued Keys* *Shotgun!Rif1e,Computer Mount, Department "PX" Key General Orders Rules and Regulations Emergency Operations Manual Field Operations Guide For Supervisors *If applicable Laptop/Desktop Computer Firearm, 3-Magazines.

Portable Breath Test Instrument Taser Taser Cartridges (3) DepartmentallD

and/or Supervisory ID Card

Driver's License* Current Issue, Status Valid

Shirt, Shoulder Patches Badge, Rank Insignia, Longevity Pi!1,Na.IDeplate, Buttons ' U.tlShield Trousers, Trouser Braid Shoes, Socks (Black) Award Ribbons Outerwear (When appropriate) Ink Pen and Pencil Field Notebook Whistle Street Guide Wristwatch Hair Mustache. Jewelry Personal Grooming

NAME

RANK

REFERENCES:

General Order 2.10 General Order 3.13 General Order 4.15

Members Identification Appearance and Dress Code Uniform and Equipment Requirements

IDENT#