The Village Police Department Citizens Police AcademyApplication for AttendanceFirst Name *Middle NameLast Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Home/Cell Phone Number *Email Address *Date of Birth *Driver's License Number *Do you own a business or are you employed in The Village? *NoYesNoIf so, where?Have you ever been arrested for, convicted of, or cited for an offense other than minor traffic violations (excluding DUI)? *NoYesNoIf yes, explain in detail, showing date, charge and action taken.Please explain why you wish to attend VPD's Citizens Police Academy *Are you currently employed? *NoYesNoName of EmployerDates of EmploymentAddress of EmployerYour TitleSupervisor NameSupervisor Phone NumberReference Name *Relationship *Reference Address *Reference Phone Number *Reference Name *Relationship *Reference Address *Reference Phone Number *Each CPA participant will be provided with, among other things, a class roster. If you are accepted, may we include your name, address and phone number on the roster? *YesYesNoPLEASE REVIEW YOUR ANSWERS CAREFULLY AND READ THE STATEMENT BELOW BEFORE SIGNING THIS APPLICATION *The answers I have given are complete and true. Further, I request former employers and any person who may have information concerning me to furnish such information to The Village Police Department. I agree to hold such persons harmless and do hereby release them from any and all liability for damages of any nature whatsoever for furnishing such information. I further understand that any omission or false statements on this application and/or any future stage of the process shall be sufficient cause for rejection for enrollment or dismissal from The Village Police Department's Citizens Police Academy. I further understand that The Village Police Department will be conducting a thorough background investigation that may include, but is not limited to, any criminal history, employment history, and personal references. I also understand that this application may be rejected for any reason without explanation. E-Signature *Date of SignatureSend MessageSave as Draft