2. 

4. APPLICATION FOR 2020 SESSION

   The 2020 Republic Police Citizen Academy starts February 21 and continues for 12 weeks. The course is held Thursday evenings between 6:30 and 7:30. Applicants must be 18 years or older, live or work in Republic, MO, and have no prior felony criminal convictions. NOTE: Class size is limited to 25 participants.
   
   If you are unable to attend this meeting, additional meetings will be scheduled throughout the year. Please watch our Facebook page for the additional meeting dates and times
   
   For questions or more information, contact Lt. Jamie Burks at 417-732-3964 or jburks@republicmo.com.

6. PERSONAL INFORMATION
8. First Name
9. Last Name
11. Date of Birth
12. Social Security Number
14. Email Address
15. Phone Number
17. Address
19. City
20. State
21. Zip Code

23. EMPLOYMENT INFORMATION
25. Employed By:
26. Your Job Title:
28. Address:
30. City:
31. Phone:

33. EMERGENCY CONTACT INFORMATION
35. Name
36. Relationship
38. Phone Number
39. Please list allergies or other medical issues:

41. QUESTIONNAIRE
43. Have you ever been arrested for a crime other than a traffic offese? If yes, please explain with disposition and dates.
45. Do you have a valid Missouri driver's license?
46. Driver's License Number:
48. Are you 18 yeas of age or older?*

    1. YES
    2. NO
49. Are you interested in a career in law enforcement?

    1. YES
    2. NO
51. Do you have any special needs that require accommodation in order for you to participate in this program? If yes, please explain:
53. How did you hear about the Citizen's Police Academy?
55. Do you know any police officers?
57. Why are you interested in participating in the Citizen's Police Academy?
59. Please list community activities, associations, or organizations in which you participate:

61. PERSONAL REFERENCES
63. Reference #1
65. Name:
66. Years Known:
68. Relationship
69. Phone:
71. Reference #2
73. Name:
74. Years Known:
76. Relationship
77. Phone:
79. Reference #3
81. Name:
82. Years Known:
84. Relationship
85. Phone:

87. SIGNATURE

    I hereby certify that there are no willful falsifications, omissions, or misrepresentations in the foregoing statements and answers to questions. I understand that any omission of false statements on this application shall be sufficient cause for rejection for enrollment of dismissal from the Republic Police Department Citizen Police Academy. I also grant permission for the Republic Police Department to verify the above information contained on the application, and to perform a criminal background check.
89. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
91. Electronic Signature
92. Date
Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit

* indicates a required field