Citizens Academy Application

I. Your information

First name *

Last name *

Email address *

Date of birth * 🛈 +

Street address *

City *

State *

Copy of Drivers License:

Zip code *

Cell Number *

T-shirt size: *

Emergency Contact:

II. Employer information

Employer name *

Street address *

Address line 2

City *

State *

Zip code *

Phone number *

Duties performed: *

III. Other information

Have you been convicted of a crime: *

If so, please explain: *

I certify that all information and statements made on this application are true and complete. I authorize any individual, company, organization or institution to release any and all information concerning statements made by me on this application, and do hereby release all parties and individuals connected therewith from all liabilities for any damages whatsoever incurred in furnishing such information.

Please acknowledge that you agree with the above statement: *

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