Sierra Vista Police Department

Citizen Police Academy Application

PLEASE PRINT LEGIBLY

1. Name: _______________________________________________________________________
(Current) Last First Middle

2. Any Other Names Used: _________________________________________________________

(please include maiden name and/or any other name changes)

2. Social Security No. ________-______-________ Date of Birth ______/______/______

Month Day Year

3. Home Address: __________________________________________ Apt.# ______________

__________________________________________________________________________
City State Zip Code

4. Mailing Address: ___________________________________________________________

(if different from home address) Street – Apt # - Post Office Box - RR # - etc.

________________________________________________________________________________________
City State Zip Code

5. Email Address: ____________________________________________________________

6. Telephone - Home: ________________ Office: _________________ Cell: __________________

7. Driver’s License Number: ________________________ State: Class: _______

Expiration Date: ______________ Is This License Currently Valid? Yes No _____

8. Have you ever been convicted of any felony or any misdemeanor involving violence or
weapons? Yes ____ No ____

If YES explain where, when, and disposition of case: ___________________________________

_______________________________________________________________________
_______________________________________________________________________

9. Place of Employment: _______________________________________________________

Address: ________________________________________________________________
Street City State Zip Code

Duties Performed: __________________________________________________________

________________________________________________________________________

1
10. Shirt Size: Polo Shirt - 100% pique-weaved cotton mesh

Circle Size - Men’s Sizes - S (30-32) M (36-38), L (40-42), XL (44-46), 2X (48-50) 3X (50-52)

11. Why do you wish to attend the Citizen Police Academy? ______________________________
___________________________________________________________________________
___________________________________________________________________________

I certify that all statements made on this application are true and complete. I authorize any individual,
company, organization or institution to release any and all information concerning statements made
by me on this application, and I do hereby release all parties and individuals connected therewith
from 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 Citizen Police Academy. My signature below acknowledges my understanding and
agreement with material provided.

_________________________

Signature Date

01/27/13 C166