Advanced Citizen Police Academy Application

Advanced Citizen Police Academy Application

Apply for the Advanced Evesham Township Police Department Citizen Police Academy. Please complete all sections accurately.
Name (Full)
Nickname / Alias
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Degree and Major
Community Resident?
Business/Property Owner? If so, which one?
Reason for enrolling in the Advanced Evesham Twp. Police Department Citizen Police Academy
Which session of the Evesham Twp. Police Department’s Citizen’s Police Academy did you attend? Did you graduate?
Associations, clubs or organizations you belong to or are affiliated with
Have you ever been arrested for, convicted of, or cited for an offense other than traffic fines?
If yes, provide details (dates, charges, location, action taken)
Have you ever been fired or asked to resign from any job in the past five years?
If yes, explain (employment separation)
Present Employer
Present Employer - Date Hired

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Present Employer - Address
Present Employer - Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Present Employer - Supervisor
Present Employer - Your Title
Previous Employer
Previous Employer - Date Hired

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous Employer - Address
Previous Employer - Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Previous Employer - Supervisor
Previous Employer - Your Title
Emergency Contact 1 - Name
Emergency Contact 1 - Relationship
Emergency Contact 1 - Address
Emergency Contact 1 - Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact 2 - Name
Emergency Contact 2 - Relationship
Emergency Contact 2 - Address
Emergency Contact 2 - Phone
Please enter a valid phone number.Format: (000) 000-0000.
Current medications and conditions for which they are prescribed
Any other medical condition or health information CPA staff should know about?
If yes, explain (other medical condition or health information)
Applicant Signature
Should be Empty: