Citizens Police Academy Application
Name
*
First Name
Middle Name
Last Name
Maiden
Social Security Number
*
Date of Birth
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
(If different from home address)
Email
*
example@example.com
Home Phone
*
Cell Phone
*
Office Phone
Driver's License
*
License Number
State
*
Expiration Date
Is this License Valid?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Have you ever been convicted of a misdemeanor?
*
Yes
No
If the answer is YES, explain when, where and the disposition of the case.
*
Do you currently have any criminal or traffic charges pending in any jurisdiction?
*
Yes
No
If YES, please explain
*
Place of Employment
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Duties Performed
*
Why do you wish to attend the Citizen Police Academy?
*
Do you currently have a family member working for the Springfield Police Division?
*
Yes
No
If YES,please list the name of this family member
*
*
I certify that all statements on this application are true and complete. I hereby authorize the Springfield Police Division to conduct a background investigation and to make an examination of the listed information for the purpose of evaluating my application. I understand that any omission or false statement on this application may disqualify me to attend the Citizen Police Academy.
Incomplete and/or unsigned applications will not be considered.
Signature
*
Email
example@example.com
Submit
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