NCPD EXPLORER APPLICATION
Applicant:
Last Name *
First Name *
Middle Name
Date Of Birth *
MM
/
DD
/
YYYY
Gender *
Ethnicity *
Email *
Street Address *
City/Town *
Zip Code *
Home Phone (NO dashes or spaces) ex. 5165551212
Cell Phone (NO dashes or spaces) ex. 5165551212 *
Cell Phone Provider (who do you pay your bill to) *
Education:
School *
Grade *
Have you ever had any disciplinary action taken against you in school? *
Explain any disciplinary action taken against you in school
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
Can you provide your own transportation to meetings and events? *
Personal Information:
Do you have a driver's license? *
License State and Number:
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:
Do you have any physical or psychological condition that will prohibit strenuous or stressful activity? *
If "Yes" above, explain condition and or limitations:
Parent/Guardian Information:
Parent/Guardian Relationship (Mother, Father, Grandmother, etc.) *
Parent/Guardian Last Name *
Parent/Guardian First Name *
Parent/Guardian Street Address *
Parent/Guardian City/Town *
Parent/Guardian Zip Code *
Parent/Guardian Email *
Parent/Guardian Home Phone (NO dashes or spaces) ex. 5165551212
Parent/Guardian Work Phone (NO dashes or spaces) ex. 5165551212
Parent/Guardian Cell Phone (NO dashes or spaces) ex. 5165551212 *
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): *
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
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy