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2. Citizens On Patrol Application
4. Personal Information:
6. Full name:*
8. Home Address:*
10. Work Address:
12. Home Telephone Number:*
13. Work Telephone Number:
15. Date of Birth:*
    Date of Birth:
16. Drivers License Number:*
17. State:*
19. Social Security Number:
20. E-Mail Address:*
22. Education:
24. High School Graduate?

    1. Yes
    2. No
25. GED?

    1. Yes
    2. No
26. Highest Grade Completed:
28. Name of High School:
30. College Graduate?

    1. Yes
    2. No
31. Degree and Major:
33. Name of College:
35. List associations, civic/service clubs, affiliations, etc:
37. Employment:
39. Presently Employed?

    1. Yes
    2. No
40. Work Hours:
42. Name of Employer:
44. Position and Duties:
46. References: (List Two References)
48. First Reference:
50. First Name
51. Last Name
53. Address
54. Phone Number
56. City
57. State
58. Zip
60. Second Reference:
62. First Name
63. Last Name
65. Address
66. Phone Number
68. City
69. State
70. Zip
72. Please list any special training / skills you have which would aide this program:
74. Are you willing to commit to patrol the minimum amount of hours required by the program per month?

    1. Yes
    2. No
76. I hereby grant permission for this law enforcement agency to conduct a criminal history background check. I am also aware that deliberately omitting or falsifying this application will be grounds for disqualification/dismissal from this program. If accepted into the program I also agree to maintain the confidentiality of any information involving any ongoing criminal investigation, police operations, arrest warrants, or criminal indictments while volunteering for this law enforcement agency.
78. Signature:*
    This a digital signature.
79. Date:*
    Date:
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field