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2. 
4. Personal Information:
6. Full Name (First, Middle, Last)*
7. Driver's License Number*
9. Preferred Contact Number*
10. Email*
12. Home Address (City, State, Zip)*
14. Occupation*
15. Employer*
17. Work Address (City, State, Zip)
19. Shirt Size:*

    1. Small
    2. Medium
    3. Large
    4. X-Large
    5. XX-Large
21. Please list any dietary restrictions:*
23. Background Information:
25. Are you a U.S. citizen?*

    1. Yes

    1. No
27. Have you ever been convicted of a crime other than a minor traffic offense?*

    1. Yes

    1. No
29. If yes, please explain:
31. Please indicate how you first learned about the Citizens Police Academy program.*

    1. Internet Search
    2. Facebook/Social Media
    3. Flyer or Brochure Handout
    4. Referred by Friend/Neighbor
    5. Referred by Police Officer
    6. Other
33. Name of officer that referred you:
35. Name of friend/neighbor that referred you:
37. How did you learn about the Citizens Police Academy?
39. Briefly explain why you wish to be accepted into the Citizens Police Academy.*
41. What do you expect to learn from this experience?
43. Do you have any reservations concerning participation in any physically-challenging or stress-related activities as part of this academy? (Examples include simulated building searches, firearms demonstrations)
45. Please list any community groups or activities with which you currently are or have been involved.
47. References:
    List three professional or personal references not related to you.
49. Name*
50. Contact Number:*
52. Address (City, State, Zip)
56. Name*
57. Contact Number:*
59. Address (City, State, Zip)
63. Name*
64. Contact Number:*
66. Address (City, State, Zip)
68. I attest that the above statements made on this application are true and complete. I authorize the Battle Creek Police Department to examine this information to evaluate my participation in the Citizens Police Academy, as well as run a driving and criminal history check to ensure that there are no disqualifiers to prohibit my participation in the Citizens Police Academy. I understand that the Battle Creek Police Department Citizens Police Academy does not certify or qualify citizens to perform any law enforcement services.*
    Please type your name above and that will serve as your electronic signature.
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70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field