NCPD EXPLORER APPLICATION
Applicant:
Last Name *
Your answer
First Name *
Your answer
Middle Name
Your answer
Date Of Birth *
MM
/
DD
/
YYYY
Gender *
Ethnicity *
Email *
Your answer
Street Address *
Your answer
City/Town *
Your answer
Zip Code *
Your answer
Home Phone (NO dashes or spaces) ex. 5165551212
Your answer
Cell Phone (NO dashes or spaces) ex. 5165551212 *
Your answer
Cell Phone Provider (who do you pay your bill to) *
Education:
School *
Your answer
Grade *
Have you ever had any disciplinary action taken against you in school? *
Explain any disciplinary action taken against you in school
Your answer
Employment:
Are you currently employed? *
If above answer was "Yes" (Full or Part Time) Enter Below: Employer, Address, Phone, Position Held (List Specific Duties), Supervisor Name
Your answer
Can you provide your own transportation to meetings and events? *
Personal Information:
Do you have a driver's license? *
License State and Number:
Your answer
Have you ever been convicted of any law violations, including traffic violations? *
If "Yes" above, state the nature of the violation, year it occurred, and locality in which it occurred:
Your answer
Do you have any physical or psychological condition that will prohibit strenuous or stressful activity? *
If "Yes" above, explain condition and or limitations:
Your answer
Parent/Guardian Information:
Parent/Guardian Relationship (Mother, Father, Grandmother, etc.) *
Your answer
Parent/Guardian Last Name *
Your answer
Parent/Guardian First Name *
Your answer
Parent/Guardian Street Address *
Your answer
Parent/Guardian City/Town *
Your answer
Parent/Guardian Zip Code *
Your answer
Parent/Guardian Email *
Your answer
Parent/Guardian Home Phone (NO dashes or spaces) ex. 5165551212
Your answer
Parent/Guardian Work Phone (NO dashes or spaces) ex. 5165551212
Your answer
Parent/Guardian Cell Phone (NO dashes or spaces) ex. 5165551212 *
Your answer
Parent/Guardian Cell Phone Provider (who do you pay your bill to) *
References
List Name, Address, Occupation, & Phone Number for References (please provide three references): *
Your answer
Certification
I certify under penalty of law, that the information given in this application is correct and complete to the best of my knowledge. I understand that false statements on this application may be considered to be a sufficient reason for disqualification. I understand that at times Explorers will be exposed to and required to participate in physical exercise and verbal confrontational situations during simulated training. I authorize the Nassau County Police Department (NCPD) to conduct any investigation of my personal history, police, and employment records. Additionally, I authorize NCPD to utilize and retain the rights to any photographs / images of myself that are taken at or during Explorer Program functions or activities.
By checking the boxes below you are electronically signing this document and acknowledging that you have read, understand, and agree with the above Certification.
Applicant Certification (to be checked by Explorer Applicant) *
Required
Parent/Guardian Certification (to be checked by Parent/Guardian of Explorer Applicant if under 18) *
Required
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