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Lubbock Law Enforcement Citizens Academy

Phone Number: *

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

YES

Date of Birth: *

List all agencies and dates attended:

(OR COMPLETE THE FORM BELOW AND SUBMIT YOUR APPLICATION)

Phone Number: *

Name (Last, First, Middle):

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: *

List any hobbies or special skills:

Friend Reference (name): *

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): *

Phone *

Email: *

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

Email: *

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AN APPLICATION TO MAIL

Name (Last, First, Middle): *

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

YES

Present Employer: *

Personal References: Employer (name): *

Have you attended a Citizens Academy before? *

YES

Have you ever been convicted of domestic violence? *

YES

Drivers License Number and State *

Work 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

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

Email: *

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

Co-worker Reference (name): *

If so, by whom:

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Address *

Present Occupation: *

Phone Number: *

Date: *

* 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.

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