2. Name:*
   Last, First, Middle
4. Date of Birth:*
   Date of Birth:
5. Email Address: *
7. Address*
9. City*
10. State*
11. Zip Code*
13. Home Phone Number:*
14. Work Phone Number:
18. In Case of Emergency Contact: Name*
19. Relationship:*
20. Phone Number:*
24. Driver's License #:*
25. State:*
27. Class:*
28. Expiration Date:*
    Expiration Date:
29. Is your driver's license valid?*
    -- Select One --YesNo
31. Have you ever been arrested for anything other than a traffic offense?*
    -- Select One --YesNo
33. If yes was answered on question #6, explain where, when and disposition.
37. Place of Employment:*
39. Address*
41. City*
42. State*
43. Zip Code*
45. Occupation: *
49. Electronic Signature Agreement*

    I certify that all 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. I agree and understand that any deliberate mis-statement or omission of material facts may disqualify me to attend the Citizens Police Academy. My signature below acknowledges my understanding and agreement with the material provided.

    1. I agree.
51. Electronic Signature*
55. Why have you volunteered to participate in the Glendale Police Department Citizens Police Academy (CPA)?*
57. What do you hope to achieve by participating in the CPA program?*
59. In your opinion, what is the crime problem(s) or source of concern within the City?*
61. How do you think the Glendale Police Department is handling the crime problem(s) at this time?*
63. What would you advise the Glendale Police Department do differently (if anything) in dealing with the crime problem(s) within the City?*
65. Do you feel that the private citizen can make a difference in the crime problem(s) within the City of Glendale? Yes or No. Why or Why not?*
67. Your shirt size for a short-sleeve police polo shirt:*
    -- Select One --XSSMLXLXXLXXXL
Leave This Blank:


69. Submit

* indicates a required field