Citizen's Police Academy Application

Name:___________________________________________________

Address:_________________________________________________

City, State, Zip:____________________________________________

Home Phone Number:_______________________________________

Occupation:_______________________________________________

Work Address:_____________________________________________

Work Telephone:____________________________________________

Date of Birth:_______________________________________________

Drivers License Number:______________________________________

Community Group or Organization Affiliation:

Why do you wish to attend the Citizen's Police Academy?


Have you ever been convicted of any crime? If so explain:


*Give names, addresses, and telephone numbers of two references:

*(Required Information)

1.__________________________________________________

 ___________________________________________________

2.__________________________________________________

____________________________________________________

Signature:_____________________________________________

Date:__________________