Russell Springs Police Department
Citizens' Police Academy
Application Information
______________________________________________________________
Name
_________________________
Date Of Birth
__________________________________________________________________________________________________
Address
___________________________________________
City
________________
State
Zip
Social Security Number
____________________________________________
Driver's License Number
Place Of Employment : __________________________________________________________________________________________________ __________________________________________________________________________________________________
Place Of Employment :
Personal References ( Please list two, provide name, address, city, postal code, and phone number ) : 1. _______________________________________________________________________________________________ 2. _______________________________________________________________________________________________
Personal References ( Please list two, provide name, address, city, postal code, and phone number ) :
1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
Have you ever been arrested for a felony? ( Circle Only One Please ) : Yes : No :
If yes, Please provide details: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
If yes, Please provide details:
_________________________________________________________________________________________________
How did you hear about this class? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
How did you hear about this class?
Why are you interested in this class? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________
Why are you interested in this class?
Upon completion of this course, how would you like your name to appear on the certificate? _________________________________________________________________________________________________
Upon completion of this course, how would you like your name to appear on the certificate?
________________________________________ Signature
________________________________________
Signature
________________________________________ Date
Date