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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. T-Shirt Size*
20. Employment Information
22. Current Employer:
23. Address
25. City
26. State
27. Zip Code
28. Phone Number
30. Emergency Contact:
32. First Name
33. Last Name
35. Address
36. City
37. State
39. Zip Code
40. Phone Number*
41. Relationship:
43. 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
44. Other:
46. Criminal History
48. Have you every been charged and/or convicted of a crime? *

    1. Yes
    2. No
49. If so, what year:
51. Drivers License:
    Please List Information:
52. State Issued:
    -- Select One --ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMHMAMIFMMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVAVIWAWVWIWY
53. Tag#
54. State Tag Issued:
56. Medical Information (Optional)
58. List Allergies and Medications:
60. Physician:
    Hospital Preference
61. Phone
62. Hospital
    -- Select One --DukeDuke RegionalUNC
64. Initals: (Required)*
65. 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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67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit Submit and Print

* indicates a required field