Smyrna Citizen's Police Academy ON-LINE Please complete all *REQUIRED fields.
NAME* (Last, First):
CURRENT E-MAIL ADDRESS:
CURRENT ADDRESS*:
CITY*:
ZIP CODE*:
HOME PHONE (area code first):
CELL PHONE (area code first):
DRIVER'S LICENSE # (include State)*:
DATE OF BIRTH (MM/DD/YYYY)*:
SEX (M or F):
EMPLOYER/SCHOOL NAME:
BUSINESS PHONE (area code first):
WHY DO YOU WISH TO ATTEND THE CITIZEN POLICE ACADEMY:
HOW WERE YOU REFERRED TO CPA?: A CPA GRADUATE BY A SMYRNA PD OFFICER NEWSPAPER/TV ARTICLE WEB PAGE OTHER
LIST ANY MEDICATIONS AND/OR ALLERGIES WE MAY NEED TO KNOW ABOUT:*
EMERGENCY CONTACT NAME:
PHONE:
HAVE YOU EVER BEEN ARRESTED FOR A FELONY OR ARE YOU CURRENTLY ON PAROLE OR PROBATION? * NO YES (A background check will be conducted on each applicant. Any intentional misrepresentation will be grounds for immediate dismissal.)
IF "YES", PLEASE EXPLAIN:
AGREEMENT: BY SUBMITTING THIS, I HEARBY ACKNOWLEDGE THAT I HAVE COMPLETED THE ABOVE INFORMATION FULLY AND ACCURATELY. I UNDERSTAND AND GIVE MY PERMISSION, WITH RESPECT TO THE SMYRNA POLICE DEPARTMENT, TO CONDUCT A BACKGROUND INVESTIGATION TO DETERMINE MY SUITABILITY FOR ADMISSION TO THIS PROGRAM? *
I AGREE TO THE CONDITIONS I DO NOT AGREE TO THE CONDITIONS
