APPLICATION FOR FEDERAL PARTICIPATION / AUTHORIZED

SCREENERS LETTER INSTRUCTIONS 

(Application Version: March 2022)

Section 1:

*Agency Name: Enter Official Agency name.

*Originating Agency Identifier (ORI) Number: Enter assigned Agency ORI number.

*Physical Address: Enter agency physical location. (ORI number should be attached to this address)

*City: Enter City of Agency/Activity

*State: Enter State Abbreviation

*Zip Code: Enter Zip Code of Agency address

*Full-Time Officers: Enter number of compensated officers with arrest and apprehension authority.

*RTD Screener Identification: “RTD Screener” - An individual(s) authorized to search items that may become available to this

agency via the Reutilization Transfer and Donation (RTD) Web. Individuals identified below may request access to act as an

authorized "RTD Screener" on behalf of this Law Enforcement Agency (Agency MUST have at least 1 RTD Screener).

*Enter Screener Title/Rank: Enter Official Title/Rank (ex. Special Agent, Admin Specialist, Property Officer)

*First Name: Enter full first name as indicated on driver’s license. (Initials will not be accepted)

*Last Name: Enter full last name as indicated on driver’s license.

*Email Address: Enter screener email address

*Phone Number: Enter screener phone number

Section 2: (Reserved for Head of Local Federal Agency Only)

Law Enforcement Agency/Activity-The LESO Program defines this as a Governmental agency, to include a division of the 

Federal Agency, whose primary function is the enforcement of applicable Federal, State and Local laws and whose 

compensated Law Enforcement Officers have the powers of arrest and apprehension.

*Certification statement checkbox: This box must be checked prior to submission to your Federal Coordinator. This check box

indicates that 1) Your agency/activity meets the definition of a “Law Enforcement Agency/Activity” as prescribed by the

LESO Program, and all information contained in this application is valid and accurate. 2) That your agency/activity will

provide an updated application for participation if any changes occur to the Head of the Local Federal Agency. 3)Agency

physical address changes. 4) RTD Screener additions or deletions. The Federal Coordinator must approve all changes.

*Title: Provide Official Title (agent in charge, field director,etc)

*Printed Name: Enter full name as indicated on driver’s license. (Initials are not accepted)

*Signature: Head of Local Federal Agency: Applications for participation cannot be signed by anyone but the head of the

agency/activity. Digital signatures will be accepted.

*Date: Enter Date of Signature. (Applications are to be submitted via email to LESO by respective LESO Federal Coordinator

Office within 30 calendar days of the CLEO signature date)

The LESO will only accept applications from the Federal Coordinators office. DO NOT send directly to the LESO.

The LESO will only accept applications from the Federal Coordinators office. DO NOT send directly to the LESO.

Section 3: (Reserved for Federal HQ Coordinator or Designee use only) 

*Printed name: Enter full name as indicated on drivers license. (Initials are

not accepted)

*Signature: Signature of Federal Coordinator. Digital signatures will be

accepted.

*Date: Enter date of signature

Section 4 : Reserved for LESO Use Only

*Indicates a required field
OFFICIAL TITLE PRINTEDNAME SIGNATURE DATE

RESERVED FOR FEDERAL HQ COORDINATOR OR DESIGNEE USE ONLY

(i.e. Property Book Officer, etc.) 

DATE 

(Application Version: March 2022

SIGNATURE

SECTION 3:

PRINTEDNAME SECTION 4:

RESERVED FOR LESO USE ONLY

DEFENSE LOGISTICS AGENCY

DISPOSITION SERVICES

74 WASHINGTON AVENUE NORTH

BATTLE CREEK, MICHIGAN 49037-3092

Law Enforcement Support Office (LESO)

Federal Application for Participation / Authorized Screeners Letter

OFFICIAL TITLE

HQ Agency (ie: DOJ/DOI):

SECTION 1:

Agency Name: 

Mailing Address (No P.O. Boxes):

State: Zip:

RTD Screener #1:

RTD Screener #2:

RTD Screener #3:

RTD Screener #4:

Agency must have at least 1 full-time officer to participate in the program. Indicate the number of compensated officers with

arrest and apprehension authority for the field activity only; not the whole Federal Agency. 

Full-time: 

RTD Screener - An individual (s) authorized to search and requisition items that may become available to this agency via the 

Reutilization Transfer and Donation (RTD) Web. Individuals identified below may request access to act as an authorized "RTD 

Screener" on behalf of this Law Enforcement Agency. Note: At least one RTD Screener is required.

I certify that my agency meets the definition of a "Law Enforcement Agency/Activity" as described above. I certify that 

all information contained in this application is valid and accurate. I understand that I must provide LESO an application to 

update my agency participant information if the following information changes: 1. Head of Local Federal Agency changes, 2. 

Agency physical address changes, or 3. RTD Screener additions/deletions. Note: Provide new or updated applications to your 

Federal Agency Coordinator.L

By signing this application, I certify under penalty of perjury that the foregoing is true and correct. 

Making a false statement may result in judicial actions or prosecution under 18 USC § 1001. 

RTD Screener #5:

NOTICE FOR DLA DISPOSITION SERVICES PERSONNEL: Regulatory guidance outlining Screener Identification and Authorization must be 

accomplished in accordance with DOD 4160.21-M, Volume 3, Enclosure 5, Section 3 (k). In accordance with the aforementioned reference, the LESO 

Program authorizes the individuals identified in Section 1 of this form to screen excess property at your facilities as authorized participants in the 

LESO Program. This authorized screener letter supersedes all previously issued screener letters for this Law Enforcement Agency/Activity and is valid 

only on or after the date signed by authorized LESO signatory. Only two individuals authorized to screen per visit; however, additional personnel may 

assist receiving material previously screened and approved for transfer.

Screener letter is valid one year from this date:

Verified Head of Local Federal Agency: All email addresses end in ".gov":

Official Title First Name Last Name Email Address Phone Number

SECTION 2:

RESERVED FOR HEAD OF LOCAL FEDERAL AGENCY USE ONLY

(i.e. Supervisor/Regional Agent in Charge/Special Agent in Charge)

Law Enforcement Agency/Activity - The LESO Program defines this as a Governmental agency, to include a division of the Federal 

Agency, whose primary function is the enforcement of applicable Federal, State and Local laws and whose compensated Law 

Enforcement officers have the powers of arrest and apprehension. 

Program Manager Signatory:

Program Manager Printed Name:

Agency DODAAC:

Federal Liaison Signatory:

Federal Liaison Printed Name:

POC conversation:

Other Notes:

As the Federal Coordinator or Designee, it has been determined that the agency meets the definition of a "Law Enforcement 

Agency/Activity" as described in Section 2. I certify that all information contained in this application is valid and accurate.

City: 

Originating Agency Identifier #: