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2. Description
   The Citizens Police Academy is a unique opportunity to educate the public about the criminal justice system and provide insight into everyday police work. Entrance into this program is by application only. Please fill out this application form in order to register for the program. A record check will be completed on each applicant.
4. Full Name*
6. Street Address*
8. City, State, ZIP Code:*
10. Home Phone*
11. Other Phone*
13. Email Address*
15. Birth Date*
16. Social Security Number*
18. Employer or Company*
20. Have you ever been convicted of a non-traffic offense?*

    1. Yes
    2. No
22. If "YES" or "Let me explain", please add comments:
24. In you own words, why do you wish to attend?*
26. How did you hear about the Academy
28. If the class is at capacity, would you like to be placed on a waiting list?

    1. Yes
    2. No
30. Agreement
    1) By submitting this form, you (the applicant) hereby certify that there are no willful misrepresentations, omissions, or falsifications in the above statements and answers to the questions. 2) "I hereby authorize the sponsoring agencies to secure criminal conviction history from appropriate law enforcement agency should it be deemed necessary to do so." 3) NOTICE: According to the Federal Freedom of Information Act, this application becomes public record, subject to disclosure under the act.
32. I have read and agree to the above*

    1. Yes
    2. No
34. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
36. Electronic Signature*
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field