2. First Name:*
3. Middle Initial:*
4. Last Name:*
6. Date of Birth (MM/DD/YYYY):*
   Date of Birth (MM/DD/YYYY):
7. Email:*
8. Phone Number *
10. Address: Street/Apartment Number*
11. City*
12. State*
14. Zip Code*
16. Emergency Contact*
17. Emergency Contact Phone Number*
19. Drivers License Number *
20. State*
21. Expiration Date*
    Expiration Date
23. Is your driver's license valid?*

    1. Yes
    2. No
25. Have you ever been arrested for anything other than a traffic offense?*

    1. Yes
    2. No
27. If you have been arrested for anything other than a traffic offense, explain where, when, and disposition.
29. Place of Employment*
30. Ocupation*
32. Are you willing to commit to attending 10 Tuesday evenings in a row from 6:00 p.m. - 9:00 p.m. beginning February 27th, 2024?*
34. Shirt Size*

    1. Small
    2. Medium
    3. Large
    4. X-Large
    5. XX-Large
36. Do you see law enforcement in a positive, negative, or neutral perspective? In your opinion, what needs to change to strengthen that relationship?*
38. By typing my name in this box, I certify that all statements made on this application are true and complete. I agree and understand that any deliberate misstatement or omission of material facts may disqualify me to attend the Citizens' Police Academy. I understand that this will serve as my electronic signature.*
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

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