Application For Enrollment - Citizen Police Academy - Memphis Police Department printable pdf download

Memphis Police Department

Citizen Police Academy

Application for Enrollment

Place

by the

Police Station

you plan to

attend

for

CPA

Classes:

Old Allen Station

____

Raines Station

____

Mt. Moriah Station

____

Union Station

____

Tillman Station

____

South Main Station

____

Airways Station

____

Ridgeway Station

____

Appling Farms Station

____

Name: ______________________________________________ DOB: ____________ Age: __________

Last name,

First name

Other Names- if applicable

Social Security Number: _______________Driver’s License/ State ID Number/State: ________________

Sex: ___________ Race: ____________ Email Address: ______________________________________

Home Address: ____________________________ City: _____________ State: _______ Zip: _________

Telephone #: Home (

) ________________ Cell (

) _____________ Work (

) _______________

Employer’s Name: _______________________________________Job Title: ______________________

Employer’s Address: ___________________________City:____________State:_______Zip:_________

Supervisor’s Name: ________________________________Contact Number: ______________________

Criminal background checks will be conducted as a requirement for CPA enrollment.

Do you consent to being subject to a criminal background check? Yes _____ No _____

Have you ever been the victim of a crime?

Yes _____ No _____

Have you ever been convicted of a crime?

Yes _____ No _____

If yes, indicate: State_________________Date______________Charges__________________________

Briefly state why you want to receive this Citizens Police Academy Training: ________________________

_______________________________________________________________________________

NOTE: All applications must be returned to your CPA Police Station’s Neighborhood Watch Coordinator.

Applications will not be accepted or processed after training begins. Qualified applicants will be selected to attend

class on a first come basis. Submitting an application does not guarantee acceptance into the class.

If selected to become a participant in the Memphis Police Department’s Citizen’s Police Academy, I do

hereby agree to attend all sessions as scheduled. I further agree to use the information obtained from the

CPA experience to help support and assist law enforcement efforts through out the community.

______________________

_______________

Applicant Signature

Date

Office Use Only: Date Received________ Initials_____ Date Approved________/Rejected______ Initials____

Application For Enrollment - Citizen Police Academy - Memphis Police Department

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