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Name

 

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If yes, Other Name:

Residential Address

Contact Information

Driver's License

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If Student

Questionnaire

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 in 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 department 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.

I have read and understand the above:

Please enter the word you see in the image below: