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2. Date
   Date
3. Name*
   Last, First Middle
5. Address
6. Phone
   (Home)
7. Phone*
   (Cell)
9. Email*
11. Date of Birth
    Date of Birth
12. Place of Birth
14. Employer
15. Immediate Supervisor
16. May We Contact?

    1. Yes
    2. No
18. Have You Ever Served in the U.S. Armed Services?

    1. Yes
    2. No
19. Branch of Service
20. Rank
22. Dates of Active Service
    Dates of Active Service Start Date

    —

    Dates of Active Service End Date
23. Type of Discharge

    1. Honorable
    2. Dishonorable
    3. Other
24. Please Explain
26. Why Do You Wish to Attend the Citizen Police Academy?
27. How Did You Hear About the Citizen Police Academy?
29. Please furnish 3 personal references. Do not list relatives or previous employers. These references must have known you for at least 2 years. Please provide all requested information, do not leave any blanks.
31. 1st Reference Name*
32. Address
34. Phone Number
35. How Long Acquainted
37. 2nd Reference Name*
38. Address
40. Phone Number
41. How Long Acquainted
43. 3rd Reference Name*
44. Address
46. Phone Number
47. How Long Acquainted
49. Have You Ever Been Arrested, Indicted, Issued a Summons to Appear, or Otherwise Charged With a Crime?

    1. Yes

    1. No

    (Include Juvenile Arrests)
51. Date
    Date
52. Charge
53. Agency
54. City
56. Explanation
58. Date
    Date
59. Charge
60. Agency
61. City
63. Explanation
65. Date
    Date
66. Charge
67. Agency
68. City
70. Explanation
72. Have You Ever Been Found Guilty or Plead No Contest to a Crime, Including Arrestable Traffic Offenses?

    1. Yes

    1. No

    (e.g. Driving While Intoxicated, Reckless Driving, Driving Revoked, Etc.)
74. Please Explain
76. Certification
    I agree to submit to the department’s selection process and understand that I must successfully complete this process before given final consideration for acceptance into the Citizen Police Academy.
    
    I hereby authorize my employer, educational institutions, and any other persons or individuals to furnish any information concerning me, whether or not it is on their records, and I release them and their companies from any liability whatsoever. I certify that all statements given on this application are true and correct. I realize that falsification or misrepresentation on this or any other personnel record may result in my not being accepted into the Citizen Police Academy. Also, in the event of acceptance and in consideration thereof, the Mitchell Police Division and any person or entity it may authorize, shall be entitled, without further consent, to use, in any manner required, any picture or photograph of me or a recording of my voice.
78. I have read and understand the above:
    Signature of Applicant*
79. 
    Date*
    
    Date
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field