Citizens' Police Academy Application
Please fill out all information to enable processing of your application and a short background check.
Applicant's Information
Please fill out all fields. Fields with a red star are required.
Last Name *
Your answer
First Name *
Your answer
Middle Initial
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Telephone Number (cell phone preferred) *
Your answer
Email Address *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Driver's License Number *
Your answer
Driver's License State *
Your answer
Emergency Contact - Name *
Your answer
Emergency Contact - Relationship *
Your answer
Emergency Contact - Telephone Number *
Your answer
References
Please provide the names of two references (other than family members).
Reference #1 - Name *
Your answer
Reference #1 - Street Address *
Your answer
Reference #1 - City *
Your answer
Reference #1 - State *
Your answer
Reference #1 - Zip Code *
Your answer
Reference #1 - Telephone Number *
Your answer
Reference #2 - Name *
Your answer
Reference #2 - Address *
Your answer
Reference #2 - City *
Your answer
Reference #2 - State *
Your answer
Reference #2 - Zip Code *
Your answer
Reference #2 - Telephone Number *
Your answer
Applicant's History
Have you ever used or experimented with narcotics, drugs, marijuana or prescription medicines, other than by prescription? *
If yes to above, please explain:
Your answer
Have you been convicted of a crime since your 18th birthday? *
If yes to above, please explain:
Your answer
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