Community Police Academy

2. Application Information
4. First Name*
5. Last Name*
7. Address*
8. City
9. States
   -- Select One --ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMHMAMIFMMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVAVIWAWVWIWY
11. Zip Code
12. Phone Number*
13. Email Address
15. What do you hope to learn during this Academy?
17. Employment Information
19. Current Employer:
20. Address
22. City
23. State
24. Zip Code
25. Phone Number
27. Emergency Contact:
29. First Name
30. Last Name
32. Address
33. City
34. State
36. Zip Code
37. Phone Number*
38. Relationship:
40. 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
41. Other:
43. Criminal History
45. Have you every been charged and/or convicted of a crime? *

    1. Yes
    2. No
46. If so, what year:
48. Drivers License:
    Please List Information:
49. State Issued:
    -- Select One --ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMHMAMIFMMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVAVIWAWVWIWY
50. Tag#
51. State Tag Issued:
53. Medical Information (Optional)
55. List Allergies and Medications:
57. Physician:
    Hospital Preference
58. Phone
59. Hospital
    -- Select One --DukeDuke RegionalUNC
61. Initals: (Required)*
62. 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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64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

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