Citizen's Police Academy Application

2. Date
   Date

3. Name

   Last, First Middle

5. Address

6. Phone

   (Home)

7. Phone

   (Cell)

9. Date of Birth
   Date of Birth

10. Place of Birth

12. Employer

13. Immediate Supervisor

14. May We Contact?

    1. Yes
    2. No

16. Have You Ever Served in the U.S. Armed Services?

    1. Yes
    2. No

17. Branch of Service

18. Rank

20. Dates of Active Service
    Dates of Active Service Start Date

    —

    Dates of Active Service End Date

21. Type of Discharge

    1. Honorable
    2. Dishonorable
    3. Other

22. Please Explain

24. Why Do You Wish to Attend the Citizen Police Academy?

25. How Did You Hear About the Citizen Police Academy?

27. 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.

29. 1st Reference Name

30. Address

32. Phone Number

33. How Long Acquainted

35. 2nd Reference Name

36. Address

38. Phone Number

39. How Long Acquainted

41. 3rd Reference Name

42. Address

44. Phone Number

45. How Long Acquainted

47. Have You Ever Been Arrested, Indicted, Issued a Summons to Appear, or Otherwise Charged With a Crime?

    1. Yes

    1. No

    (Include Juvenile Arrests)

49. Date
    Date

50. Charge

51. Agency

52. City

54. Explanation

56. Date
    Date

57. Charge

58. Agency

59. City

61. Explanation

63. Date
    Date

64. Charge

65. Agency

66. City

68. Explanation

70. 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.)

72. Please Explain

74. 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.

76. I have read and understand the above:
    Signature of Applicant*

77. 
    Date*
    
    Date

Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field