- Citizen Police Academy

Community Policing Updates and Quarterly Newsletters

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Please complete the following form to apply for the next Citizen Police Academy which starts on Wednesday, September 12, 2012. This is a 10 week program, and meets every Wednesday night from 6pm to 9pm. There is no cost to attend, and you must be 18 years of age to apply.

• You must be at least 18 years of age
• You should live or work in the City of San Rafael
• You must not be convicted of a felony, or prohibited from owning or possessing a firearm
• Applications must be received by August 31, 2012

** This application is for the September 2012 class. The February 2012 class is full. **

Applicant Information:

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First Name:
Middle Name:
Last Name:
Alias:
Date of Birth:	(You must be at least 18 years of age)
Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Home Phone:
Office Phone:
Other Phone:
Email Address:

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Drivers License Number:
Drivers License State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Drivers License Class:
Drivers License Expiration Date:
Is your Drivers License Currently Valid?	YES NO

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Have you ever been convicted of any felony? YES NO
If yes, please explain where, when, and disposition:

Place of Employment:
Employer Address:
Duties Performed:

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How do you feel the citizens' police academy will benefit you?


What is your opinion of the San Rafael Police Department?

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I hereby certify that the answers are true and correct. By pressing "Submit", I authorize any of the academy law enforcement agencies to do a criminal history and background check for the purposes of this academy.