Citizens Police Academy Applicant

All appicants must be 18 years of age. Incomplete or unsigned applications will not be consideredand will be disqualified.

Name*

PrefixFirst NameMiddle NameLast NameSuffix

Nickname/Alias

SSN*

Date of Birth*

Date

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Alt Phone Number

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer Name

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Job Title

Work Phone Number

Please enter a valid phone number.

Are you a US citizen?*

If no, what is your permanent resident card number?

How did you hear about the academy?

Drivers License Number

State

Expiration Date

Level Of Education*

Why would you like to attend the academy?*

0/0

Have you ever been arrested?*

Have you ever been convicted of a crime or offense?*

If yes, Please provide details (i.e., date, reason, outcome and etc).

Have you ever attended a citizen academy presented by a police department?*

Will you require any special accommodations to participate in the class?*

If yes, Please explain

I hereby certify that all statements made on this application are true and complete to the best of my knowledge. I understandthat by participatingin the Glendale Police Department's Citizen Academy,I will have accessto facilities, areas andequipment not generally available to the generalpublic. Therefore,I am
providingthe information onthis application andI am authorizing the Glendale Police Department to verify that I am not the subject of an on-going criminal investigation, am not involved in any civil litigation with the City of Glendale,I do not haveany misdemeanor convictions within thelastthreeyears and have
never been convicted of any felonies. I understand that a background check will be conducted on me to make a determination thatI am not disqualified from participation in the Citizen Police Academy. I authorize any individual, company, organization, or institution to release any and all information concerning statements
made by me on this application, and I hereby release all parties and individuals connected therewith from all liabilities for any damages whatsoever incurred in furnishing such information. I agree and understand that any deliberate misstatement or omission of material facts may disqualify me to attend the Glendale Police Department's Citizen Academy. My signature below acknowledges my understanding and agreement with the material provided.

Signature*

Clear

Date*

Date