Citizen's Academy Application

First Name *

Last Name *

Date of Birth *

Month

Day

Year

Phone Number *

Email Address *

Address *

City *

State *

Zip Code *

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

Yes

No

If yes, explain where, when and disposition

Emergency Contact Name *

Relationship *

Emergency Contact Phone Number *

Signature (Type Full Name) *

By submitting this form, I certify that all statements made on this application are true and complete. I authorize any individual, company, organization or institution to release any and all information concerning statements made by me on this application and do hereby release all parties and individuals connected therewith from all liabilities for any damages whatsoever incurred in furnishing such information. I agree and understand any deliberate misstatement or omission or material facts may disqualify me from attending the Citizens’ Police Academy.