1

Name

 *

Name

2

Home Address

 *

Home Address

Street Address

City

Zip Code

3

Contact Information

Contact Information

Daytime Phone Numberext.

Evening Phone Numberext.

Email Address

4

Gender

Gender

Male

Female

5

Birth Information

Birth Information

Date of Birth

Place of Birth

6

Driver's License Information

Driver's License Information

Driver’s License Number

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Expiration

7

Emergency Contact

Emergency Contact

Name

Daytime Phone Numberext.

Evening Phone Number

8

Employer Information

Employer Information

Employer Name	Employer Address
Job Title	Length of Employment

9

Personal Reference 

Personal Reference

#1 Name	#1 Phone Numberext.	#1 Email Address
#2 Name	#2 Phone Numberext.	#2 Email Address

10

Community/Civic Organization participation (if any)

Community/Civic Organization participation (if any)

11

Why do you wish to participate in the Citizens' Police Academy?

Why do you wish to participate in the Citizens' Police Academy?

12

If you are not a City of Santa Clara resident, what tie(s) to you have with SCPD or our city?

If you are not a City of Santa Clara resident, what tie(s) to you have with SCPD or our city?

13

Have you ever had any contact with the SCPD? If so, was your experience positive or negative? Please describe.

Have you ever had any contact with the SCPD? If so, was your experience positive or negative? Please describe.

14

Have you ever applied to work for the City of Santa Clara? If so, in what capacity?

Have you ever applied to work for the City of Santa Clara? If so, in what capacity?

15

Are there any physical limitations we need to be aware of in order to be able to better assist you to engage in the activities associated with the Citizens Police Academy?

Are there any physical limitations we need to be aware of in order to be able to better assist you to engage in the activities associated with the Citizens Police Academy?

16

Can you commit to attending all the classes?

Can you commit to attending all the classes?

YES

NO

If not, please provide dates you cannot attend:

17

Are you at least 21 years of age?

Are you at least 21 years of age?

YES

NO

18

Have you ever been arrested?

Have you ever been arrested?

NO

YES

If so, please provide details (date, location, summary of the incident, disposition)

19

Have you received a non-traffic related citation?

Have you received a non-traffic related citation?

NO

YES

If so, please provide details (date, location, summary of the incident, disposition)

20

Have you ever been convicted of a criminal offense?

Have you ever been convicted of a criminal offense?

YES

NO

21

Are you currently on probation? 

Are you currently on probation?

YES

NO

22

Are you currently on parole?

Are you currently on parole?

YES

NO

23

Certification and Authorization

Certification and Authorization

(Initials) I certify that the statements made by me in this application are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I understand that falsification, misrepresentation or omission of facts called for by the application could result in immediate dismissal in this program.

(Initials) I authorize the City of Santa Clara the right to contact and obtain information from all references, employers, educational institutions, and law enforcement agencies, and otherwise verify the accuracy of the information contained in the application. I hereby release from liability the City of Santa Clara and its representative from seeking, gathering and using such information and all other person, corporation or organization from furnishing and disclosing information.

(Initials) I agree to report all contact(s) (e.g. speeding ticket, arrest, etc.) with any law enforcement agency during the course of the Citizen's Police Academy to the Management Analyst or Lieutenant immediately.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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