Clark County Sheriff's Office Citizen Academy
Please fully complete this application. Applications that are not completed fully will not be considered.
Date
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First Name
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Last Name
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Middle Initial
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Address 1
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Address 2 (Optional)
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City
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State
Date of Birth
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DD
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YYYY
State of Birth
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Driver's License Number
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Driver License State
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Phone Number
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Email Address
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Have you ever been convicted of a crime (Misdemeanor or Felony)?
If YES, List date and offense
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Place of Employment
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I certify that all statements made on this application are true and complete to the best of my knowledge. I authorize any individual, company, organization or institution to release any and all information concerning statements made by me on this application, and I do herby release all parties and individuals incurred in furnishing such information. I agree and understand that any deliberate misstatement or omission of material facts may disqualify me to be a member of listed organization. My digital signature below acknowledges my understanding and agreement with material provided. (FIRST NAME MIDDLE INITIAL LAST NAME: JOHN R. SMITH)
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