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2. Citizen Police Academy Application
4. Application for Enrollment
6. First Name*
7. Last Name*
9. Address*
11. City*
12. State*
13. Zip*
15. Business Address
17. City
18. State
19. Zip
21. May we give your home phone number to CPA students?

    1. Yes
    2. No
22. Home Phone:
23. Work Phone:
25. If less than 2 years at present address, please list your previous address:
27. Address
29. City
30. State
31. Zip
33. Profession:
35. Date of Birth:
    Date of Birth:
36. Gender:

    1. Male
    2. Female
37. Drivers License Number:
39. Have you ever been arrested? If yes, what offense?
43. References:
45. Remember to select individuals who can attest to your work ethic, academic performance, skills and abilities. Do not ask family members to be references for you. Please submit Employer and two (2) Personal references.
47. Reference #1
49. Name*
50. Title*
52. Reference Type*

    1. Employer
    2. Personal
53. Address
55. City
56. State
57. Zip
59. Phone Number
60. Email
61. Years worked/Known Person
63. Reference #2
65. Name*
66. Title*
68. Reference Type*

    1. Employer
    2. Personal
69. Address
71. City
72. State
73. Zip
75. Phone Number
76. Email
77. Years worked/Known Person
79. Reference #3
81. Name*
82. Title*
84. Reference Type*

    1. Employer
    2. Personal
85. Address
87. City
88. State
89. Zip
91. Phone Number
92. Email
93. Years worked/Known Person
97. PLEASE READ AND SIGN: I understand that prior to acceptance, applicants will be investigated for prior criminal offenses. A prior conviction will not automatically disqualify an applicant. The facts set forth in my application are true and correct. The Midland Texas Police Department is hereby authorized to make any investigation of my personal history deemed necessary for consideration of entry to the Citizen Police Academy.
99. Applicant Signature:*
    This is a digital signature
100. Date:*
     Date:
Leave This Blank:


102. 1. Receive an email copy of this form.
103. Email address

     This field is not part of the form submission.

104. Submit

* indicates a required field