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2. Select one of the following:

   1. Basic Academy
   2. Advanced Academy
   3. Senior Academy
4. Date
   Date
6. First Name
7. Last Name
9. Address
11. City
12. State
13. Zip Code
15. Date of Birth
17. Home Phone Number
19. Work Phone Number
21. Email Address
23. Occupation
25. Employer
27. Years Employed (current employer)
29. Former Employers
31. Education
    Please include level and school attended.
33. Special Training
35. Two Character References
    Please provide names and addresses.
37. List any Roanoke Police Officers that you know
39. Can you attend all classes?
    If no, please explain why.
41. Are you involved in the community?
    If so, how?
43. Why do you want to participate in the Citizen Police Academy?
45. What do you hope to gain from this program?
47. If you're not selected, would you be interested in attending a future academy?

    1. Yes
    2. No
49. Please read carefully:*

    By checking the box below, I hereby make application for the Citizen Police Academy sponsored by the Roanoke Police Department. I understand that a standard background check will be made using the information I have provided, including a criminal history and DMV history. I also understand that a “RIDE ALONG PROGRAM”, DEFENSIVE TACTICS DEMONSTRATION, FIREARMS DEMONSTRATION and OPERATION OF A POLICE VEHICLE are part of the Citizen Police Academy and that I will be required to complete the necessary waivers provided by the Roanoke Police Department. I hereby certify that all statements made in this application and any attachments are true and complete to the best of my knowledge, and I understand that any misstatement of material facts may subject me to disqualification or dismissal.

    1. I agree to the above statements
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51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field