Citizens Police Academy Application

Tennessen Warning, Minn.Stat.13.04, Subd. 2
The information requested on this form will be used for consideration of your participation in Moorhead Police Department's Citizens Police Academy (CPA). Its intended use is to assist Police Department personnel to conduct a background check to verify eligibility of participating in the CPA. You are not legally obligated to supply the data. However, failure to do so could result in this department's inability to conduct a background check which is required to verify eligibility to participate in the CPA. Persons authorized to access information include Police Department personnel.

General Information

1

First Name:

First Name

2

Middle Name:

Middle Name

3

Last Name:

Last Name

4

Date of Birth:

Date of Birth

5

Address:

Address

6

City:

City

7

State:

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

8

Zip:

Zip

9

Home Phone:

Home Phoneext.

10

Work Phone:

Work Phoneext.

11

Cell Phone:

Cell Phoneext.

12

Email Address:

Email Address

13

Shirt Size:

S

M

L

XL

2XL

Drivers License

14

Drivers License #:

Drivers License #

15

State Issued:

State Issued(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Employer Information

16

Employer:

Employer

17

Occupation:

Occupation

18

Employer's Address:

Employer's Address

19

City:

City

20

State:

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

21

Zip:

Zip

Emergency Contact

22

Contact Name:

Contact Name

23

Address:

Address

24

City:

City

25

State

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

26

Telephone Number:

Telephone Numberext.

27

Relationship

Relationship

Questions

28

Have you ever attended a Citizens Police Academy of any kind in the past?

Yes

No

29

If yes, which one?

If yes, which one?

30

Have you been arrested for any offense other then traffic violations?

Yes

No

31

If yes,  What for ?

If yes, What for ?

32

When?

When?

33

Where?

Where?

34

List/Describe any civic activities or organizations you are involved in:

List/Describe any civic activities or organizations you are involved in:

35

What experience have you had with law enforcement?

Positive

Negative

36

Briefly Explain

Briefly Explain

37

How did you hear about our Citizens Police Academy? 

How did you hear about our Citizens Police Academy?

38

Why are you interested in the Citizens Police Academy?

Why are you interested in the Citizens Police Academy?

39

What do you expect to gain from attending this academy?

What do you expect to gain from attending this academy?

40

I UNDERSTAND THAT SPACE IS LIMITED, ALLOWING ONLY 24 STUDENTS TO PARTICIPATE IN THE CITIZENS POLICE ACADEMY. THEREFORE, I AGREE TO ATTEND AT LEAST 8 OF THE 10 SCHEDULED SESSIONS. ADDITIONALLY, I AGREE TO ARRIVE PROMPTLY AND TO COMPLETE AND RETURN THE EVALUATION FORM PROVIDED FOR EACH SESSION.

 *

41

I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. YOU ARE HEREBY AUTHORIZED TO MAKE ANY INVESTIGATION OF MY PERSONAL HISTORY DEEMED NECESSARY FOR CONSIDERATION TO ATTEND THE CITIZENS POLICE ACADEMY.

 *

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