Citizen's Police Academy Application

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