Community Police Academy

2. Application Information
4. First Name*
5. Last Name*
6. Date of Birth*
   Date of Birth
8. Address*
9. City
10. States
    -- Select One --ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMHMAMIFMMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVAVIWAWVWIWY
12. Zip Code
13. Phone Number*
14. Email Address
16. What do you hope to learn during this Academy?
18. Employment Information
20. Current Employer:
21. Address
23. City
24. State
25. Zip Code
26. Phone Number
28. Emergency Contact:
30. First Name
31. Last Name
33. Address
34. City
35. State
37. Zip Code
38. Phone Number*
39. Relationship:
41. How did you hear about the academy? ( Select all that apply)

    1. Facebook (DPD/City)
    2. Newspaper
    3. Durham TV Network
    4. National Night Out
    5. Website (DPD/City)
    6. Civilian Police Review Board
    7. Partners Against Crime (PAC
42. Other:
44. Criminal History
46. Have you every been charged and/or convicted of a crime? *

    1. Yes
    2. No
47. If so, what year:
49. Drivers License:
    Please List Information:
50. State Issued:
    -- Select One --ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMHMAMIFMMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVAVIWAWVWIWY
51. Tag#
52. State Tag Issued:
54. Medical Information (Optional)
56. List Allergies and Medications:
58. Physician:
    Hospital Preference
59. Phone
60. Hospital
    -- Select One --DukeDuke RegionalUNC
62. Initals: (Required)*
63. Consent:
    I certify that the information in this application is true and complete to the best of my knowledge. I also grant permission for the Durham Police Department to verify the above information contained on this application and check for prior criminal history. My initials below acknowledge that the above information is true and correct to the best of my knowledge.
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65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

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