Personal Information

Name:*

Address:*

City:*

State:*

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Zip:*

Contact Ph:

Email:

Date of Birth:*

DL#:*

Employment Information

Occupation:*

Employer:

Employer Address:

Employer Phone:

Background Information

Have you ever been arrested for anything other than a traffic offense?*

Yes

No

If yes, what for?

If yes, where?

If yes, when?

Class Information

What is it you expect to gain from attending this program?*

What shirt size do you wear?

M L

XL 2XL

Certification/Authorization

I hereby certify that the information contained in this application is true and complete to the best of my knowledge. You are hereby authorized to make any investigation of my personal history deemed necessary for consideration to attend the Citizen's Police Academy.

I agree with the above statement.*

Yes

No

Signature:________________________________________

Date:_____________________________________________