Citizen's Academy Application

							
							Last Name*						

							First Name*						

							Middle Name						

							Social Security #*						

							Have you ever been known by any other name/last name?*						

Yes

No
If yes, Other Name:

							Alternate Last Name						

							Alternate First Name						

							Alternate Middle Name						
Residential Address

							Number*						

							Street*						

							City*						

							State*						

							Zip*						

							Parish or County*						

							How long at this address?						
Contact Information

							Residential Phone Number						

							Cell Phone Number*						

							Email Address*						
Driver's License

							Do you hold a current, valid driver's license?*						

Yes

No

							State						

							Driver's License #						

							Expiration Date						
If Student

							Name of School						

							Course of Study						

							School Phone						

							Employer						
Questionnaire

							Why do you wish to attend the Citizen Police Academy?						

							How did you first hear about the Citizen Police Academy?						

							Have you ever been arrested, incarcerated, indicted, issued a notice to appear, or otherwise charged with a crime?						
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:

							Date*						

							Initials*						

							State Of*						

							Please enter the word you see in the image below:

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Citizen's Academy Application

If yes, Other Name:

Residential Address

Contact Information

Driver's License

If Student

Questionnaire

Certification