Citizen Police Academy Application

Citizen Police Academy Application

Arlington Heights Police Department
Full Name*

First NameLast Name
Full Address

Street Address

CityState

Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Gender
Drivers License Number
State Drivers License was Issued
Is your Drivers License Valid?

YesNo
Have you ever been arrested for anything other than a traffic offense?

YesNo
If Yes, explain When, Where and Disposition
Occupation
Place of Employment
Employers Address

Street Address

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact's Address

Street Address

CityState / Province

Postal / Zip Code
Emergency Contact's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact
As a way of promoting the Citizen Police Academy (CPA), photographs and video imagery may be taken during academy sessions which might be used on the Arlington Heights Police Department's website or appear in local newspapers.

I certify that all statements made on this application are true and complete. I certify that I am at least 21 years of age and agree to allow the Arlington Heights Police Department to conduct a background check prior to my participation in the CPA. I agree and understand that any deliberate misstatement or omission of material facts may disqualify me to attend the CPA.

My signature below acknowledges my understanding and agreement with the material provided.
I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.
Sign Here
Date

MonthDayYear
Date
Should be Empty: