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Step One

Business Name
Business Address
City
State
Zip
Occupation or Job Title
Referred by: (Name, Address, Phone)
May we place your name, address and phone number on a class roster?
1. Yes
1. No
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In case of emergency, please call: (Name and phone number)
Reference #1 (Name, Address & Phone number)
Please list 3 references
Reference #2 (Name, Address & Phone number)
Reference #3 (Name, Address & Phone number)
Describe in your own words why you are interested in attanding the Citizens Police Academy:
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Have you ever been arrested for any offense other than a traffic offense?
1. Yes
1. No
If yes, state the charge(s), date, location of arrest and disposition:
I hereby authorize the Cleburne Police Department to make an examination of my background and references for the purpose of evaluating my application. I also understand that any arrest or falsification of any information included in this application may be grounds for rejection of my application.
Electronic signature constitutes authorization.
Date of Application
Date of Application

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