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Email: *

Signature of Applicant (Please just type your name in the space below as your signature for this online application): *

Polo Size (Male or Female; S, M, L, XL, XXL, XXXL): *

Please list an Emergency Contact (address, home phone, & cell phone): *

Were you recommended or advised to apply to the Citizens Academy? *

YES

I understand that any false or misleading information stated on this application could result in the removal of my application. I certify my information on this application is true *

YES

Co-worker Reference (name): *

If so, by whom:

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Address *

Present Occupation: *

Phone Number: *

Date: *

Phone Number: *

I understand and agree that a background investigation will be conducted in order for me to attend this Academy *

YES

Email: *

Please explain briefly why you wish to enroll into the Citizens Academy: *

Have you attended a Citizens Academy before? *

YES

Email: *

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* Applicants must be at least 18 years of age and may not have criminal charges pending. Incomplete, inaccurate, or unsigned application will not be considered.

List all agencies and dates attended:

(OR COMPLETE THE FORM BELOW AND SUBMIT YOUR APPLICATION)

List any hobbies or special skills:

Do you have any past arrests, convictions, or pending court cases? *

YES

If you answered "YES" to the above questions, please list the date, agency, charge, and disposition. Attach any additional information if necessary.

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AN APPLICATION TO MAIL

List any organizations you are presently member of or have been: *

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Phone Number: *

Email: *

Work Phone: *

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Date of Birth: *

Friend Reference (name): *

Have you ever been convicted of domestic violence? *

YES

Lubbock Law Enforcement Citizens Academy

Medical and Emergency Contact Information: To get the greatest benefit from the Citizens Academy, students should be able to stand for periods of time, walk moderate distance and be exposed to the outside elements of weather. If you are unable to do this, the Department can provide reasonable accommodations to those students who can identify special assistance needs in advance. if you need assistance or accommodation, please identify the assistance you need here in the space below: *

Name (Last, First, Middle):

Name (Last, First, Middle): *

Phone *

Personal References: Employer (name): *

Present Employer: *

Drivers License Number and State *