Name: ________________________________________________________________________

Address: ______________________________________________________________________

City / Zip: ____________________________________     Date of Birth: ___________________

Home Phone #: _________________________    E-mail: _______________________________

Driver’s License #:___________________________   State: ________ 

Occupation: ____________________________________________________________________

Work Phone #:__________________________

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 hereby 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:   

                                   Sgt Michael Hashey, CPA Coordinator

                                        Old Town Police Department

                                               150 Brunswick St

                                             Old Town, ME 04468