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Old Town Police Department Citizen Police Academy Application for Enrollment
Name: _____________________________________ Date: ______________________ Address: ________________________________________________________________ City / Zip: ________________________________ Date of Birth: ________________ E-Mail Address: __________________________________________________________ Driver’s License #:_____________________ State: ______ SS# : ________________ Home Phone #: _________________________ Work Phone #:____________________ Occupation: _____________________________________________________________ Community Group Affiliation (if any): _________________________________________ ________________________________________________________________________ Why do you wish to attend the Citizen Police Academy? ________________________________________________________________________ ________________________________________________________________________ How did you hear about the Citizen Police Academy? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________
List two references: 1. __________________________________________ Phone #: ________________ 2. __________________________________________ Phone #: ________________
I authorize the Old Town Police Department to conduct a background investigation to obtain any information relating to my criminal history record for the purpose of making a determination of eligibility for the Citizen Police Academy.
Signature: ________________________________________________ Date: __________
Please mail completed form to: Officer Lori Renzullo, CPA Coordinator Old Town Police Department 150 Brunswick St Old Town, ME 04468 |