2017-106 ,.. `, FLORIDA DEPARTMENT OF LAW E +'ORCEMENT , '`
.' = `I 1 C AL JUSTICE INFO TION SERVICES i e II,
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=--ter CJIS AGENCY CONTACT FORM14 ; + '
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The Florida Department of Law Enforcement(FDLE)Criminal Justice Information Services(CJIS)Users'Agreement
requires each agency to appoint designated contacts to include the Terminal Agency Coordinator(TAC)and the Local
Agency Security Officer(LASO).Other appointments may include the FALCON Application Access Administrator(AAA),
Public Access_System(PAS),and other contacts listed below. Upon receiving this form the TAC will be contacted by the
Regional CJIS Information Delivery Team(IDT)Member to discuss training available for some of these appointed
positions.
Enter the pertinent information into this form and return it to FDLE by fax or email. Scanning and emailing the form to
CJISIDT@fdle.state.fl:us is the preferred method. However, if your agency is unable to send this form electronically,then
you may return the form by faxing it to(850)410-7125.
Date: 1012312017
Agency Name: 0.- ermo()+- i l 1 C C pa(+Mps JT Agency OW: FL 1 J 56 3
Physical Address: '3 (POU S- U c /kip V1 C letmor14- Fl- 311-`7 I. 1
Chief Executive or Official's Signature: ti
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Chief Executive or Official's Printed Name: Char IfS ` 3Y j) ..
Terminal Agency, Coordinator(TAC) R "�,,-�
Name: �C a r< lin �,c d Ca�_ Title: gg "L• 0 C —+'7n VM!J'1q -h D�S
Phone#:3.52 -53(o ." O O Cell Phone: / Fax:
E-mail Address: SS-hi cdc land a 0.[�.rmofl4-,Cf. o r9
Alternate Terminal Agency Coordinator(ALT TAC) J
Name:GlAdlDVIQ, ,4rT0g0• rit2eCDr 'i1S 3-6.-Cc Qssi$-f&rj+-
Phone#:3'5"Q .5 19 424- Cell Phone: Fax a5.2 :3614- I LA
E-mail Address: P o r r o L{b ()Clermont--P 1.org-
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Local Agency Security Opfer(LASO)
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Name: w&Lt1 D vintAjn • Title: 311.5-1" r m AdO1i -rcd()1- f
Phone#:352' 241 ' f ,5-7L. Cell Phone: ` V '7 • 3) •O O 17 Fax:
E-mail Address: 1,1)-CDU,n 11r(,t inCti? Oki-monk-A. or'q .
nexTEST Administrator `�
fi
Name:_ S►'10117 e 5T/1'cKlanr) • Title: Q1 � q. oP �lvveeh. C�4436Y)Phone#: 3.S2 5 3�//P -811'03 Cell Phone: Fax: J
E-mail Address: • C K l arl d 0 C(ermc() -�)- Dy{3
Secondary notification email address: I-a r 9i.j 0 6)0.1 er rYl ] 41 1 • 0 Y-'G(
CTBS-027 J
10/2015
CJIS Agency Contact Form
Date: Agency ORI: FL 0 3 S "39 C? ..
Agency Name: Clermont- 1)016e bt Agency Head Initials: �, •
CJIS Online(Security Awareness Training)Administrator
Shane 11 J
Name: �/ f�l(d.flo(Q+ Title: ��•
Phone#:352•� 3/e TO D Cell Phone: Fax:
E-mail Address: ss4r1'e-klanCJ ancl€rmclot- l-ory
FALCON Application Access Administrator(AAA) , -
First Name: ane Middle Initial: Last Name:SJY!c.xlk o/
Phone#. " S2 .5510• 1-1(:)(g Cell Phone: Fax
E-mail Address:
S-S4ri CKland P cterrnt204- -r1® Or
G
THE FOLLOWING DESIGNATIONS PERTAIN TO ENTRY AGENCIES ONLY
Valida' ns Administrator ±:
.e ('n -
Name. Title:
I i'
Phone#: Cell Phone: Fax:
E-mail Address: I'
PublicAccess System(PAS)Contact -
Name: to C ,fill- Cl Title:
Phone#: Cell Phone: Fax
i
E-mail Address:
PAS Tip E-mail Address: PAS Tip Phone#:
1 If you have any questions regarding this form, please email CJISIDT(altfdte.state.fl.us.
ii
i
CTBS-027 1012015