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