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CITIZEN POLICE ACADEMY APPLICATION FORM For citizens residing or working in the City of York Date of application Name First middle last Address City State Zip Code Home phone Work or Cell Email Address Driver s License State Occupation Birth Date Employer Work Address Supervisor s Phone Have you ever been arrested Yes No If yes please explain including when and where the incident occurred What past personal experience have you had involving a law enforcement officer Positive Negative Please briefly explain Why are you interested in attending the Citizen Police Academy Briefly explain What do you expect to gain from this program Dates Tuesday Thursday evenings 6-8 30 PM. June 5th June 28th 2012. First Class will convene at Fire Hall Station 9 located at 800 Roosevelt Ave. Listed an emergency contact name Relationship Address Phone By signing below I hereby certify that the information above is true and further that the Police Department is duly authorized to make any investigation of my personal history deemed necessary for consideration in order for me to attend the Citizen Police Academy. Signature Please return to Community Services Division Attention Lt. Fells or Jacqueline Marrero PO Box 509 York PA 17405 717-846-1234. June 5th June 28th 2012. First Class will convene at Fire Hall Station 9 located at 800 Roosevelt Ave. Listed an emergency contact name Relationship Address Phone By signing below I hereby certify that the information above is true and further that the Police Department is duly authorized to make any investigation of my personal history deemed necessary for consideration in order for me to attend the Citizen Police Academy. Listed an emergency contact name Relationship Address Phone By signing below I hereby certify that the information above is true and further that the Police Department is duly authorized to make any investigation of my personal history deemed necessary for consideration in order for me to attend the Citizen Police Academy. Signature Please return to Community Services Division Attention Lt. Fells or Jacqueline Marrero PO Box 509 York PA 17405 717-846-1234. June 5th June 28th 2012. First Class will convene at Fire Hall Station 9 located at 800 Roosevelt Ave. Listed an emergency contact name Relationship Address Phone By signing below I hereby certify that the information above is true and further that the Police Department is duly authorized to make any investigation of my personal history deemed necessary for consideration in order for me to attend the Citizen Police Academy. Signature Please return to Community Services Division Attention Lt. Fells or Jacqueline Marrero PO Box 509 York PA 17405 717-846-1234.

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