TUCSON POLICE DEPARTMENT

CITIZENS' POLICE ACADEMY

Application

AUTHORIZATION FOR RELEASE OF INFORMATION

I, , DO HEREBY AUTHORIZE government entities, military agencies, law enforcement agencies, City, County, and Federal entities, private persons, and employers, to furnish and release any and all available information relating to me for the purpose of determining my suitability to be appointed as a member of the CITIZENS' POLICE ACADEMY.

I DO HEREBY RELEASE from liability, all persons or entities disclosing information pursuant to this release.

STATEMENT OF PERSONAL HISTORY AND APPLICATION

INSTRUCTIONS: Read and answer every question carefully. Do not leave blank spaces; if the question does not apply to you, print or type "DNA" in that answer block. Incomplete or unsigned statements cannot be processed. All information provided is subject to verification. The information on this form may contain a "public record or other matter" requiring public disclosure under Arizona's Public Record Law, A.R.S. 39-121 et seq.

1.Name:(Last, First, Middle)

2.Address:

 		 3.City:
 4.State / Zip:

5.Home phone:
 

 6.Date of Birth:

7.Place of Birth:

8.Social Security Number(optional):

9.Email Address

10.Previous Address: (list all for past 5 years: use reverse side if needed)

 

11.If you have used any other names, DOBs, or SSNs, list here:

Maiden Name:

 

12.Name of Employer: (Years/Months)

13.Work Phone:

14.Supervisor:
 

15.Current Driver's License Number:
 

16.State:

17.Expiration Date:

18. Why do you wish to attend the Citizens' Police Academy?

REFERRED BY:

 

Name: Date:

If you have questions regarding the Citizens' Police Academy, call 791-5211, ext. 1116.