Read carefully before filling out this form:

Due to the sensitivity and classified nature of the material that will be shared with you during the Public Safety Citizens Academy, it is essential that each applicant complete this application thoroughly and truthfully. It is imperative to the security of our agency that each accepted applicant is of good moral and legal standing. All applicants must pass a criminal history background check before participating in the Public Safety Citizens Academy.

All questions must be answered, if applicable. If not, indicate N/A (not applicable). Applications that are not complete and legible will not be considered. The information you provide in this application will remain confidential. You are responsible for obtaining correct addresses, to include street addresses, state and zip code.

First Name: *

Middle Name:*

Last Name: *

Phone Number: *

Street Address: *

P.O. Box (If applicable. If not applicable, type N/A) *

City: *

State: *

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip Code: *

Race: *

Sex:

Male

Female

Height:*

Weight: *

Hair Color: *

Eye Color: *

Date of Birth (mm/dd/yyyy): *

City of Birth: *

Social Security #: *

Driver License #: *

Driver License State: *

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Driver License Expiration Date (mm/dd/yyyy):*

Briefly explain why you would like to enroll in the Public Safety Citizens Academy: *

Legal History (Note - A Conviction includes a guilty plea, payment of a traffic or other fine without court appearances, or a court conviction of a criminal or traffic offense. An Arrest constitutes being taken into police custody.):

If the answer to any of the following questions is yes, please explain in detail. Give date, place, charge, and final disposition in each case.

Have you ever been arrested for an offense other than a traffic violation?

Yes

No

If yes, explain in detail including date, charge, place and final disposition. If no, type N/A.*

Have you ever been arrested for a traffic offense (example: DUI, DWI, Driving with a suspended or revoked License, etc):

Yes

No

If yes, explain in detail including date, charge, place and final disposition. If no, type N/A.*

Have you ever illegally possessed any drug or controlled substance that was not prescribed to you by a medical professional or given to you to hold while you were acting on behalf of, or employed to do so, by a law enforcement agency?

Yes

No

If yes, explain in detail including date, charge, place and final disposition. If no, type N/A.*

Have you ever illegally sold, given or distributed any drugs or controlled substances?

Yes

No

If yes, explain in detail including date, charge, place and final disposition. If no, type N/A.*

Education:

Have you been fired from or asked to resign from any job in the past five years?

Yes

No

If yes, explain. If no, type N/A.*

List information regarding the last two jobs you have held (include: retired, unemployed, stay at home parent, etc. if applicable):

Present Employer: (if not employed, type N/A). *

Date Hired: mm/dd/yyyy (If unemployed, type N/A). *

Address: (If unemployed, type N/A). *

Phone: (If unemployed, type N/A). *

Supervisor (If unemployed, type N/A). *

Your Title: (If unemployed, type N/A). *

Previous Employer: (if no previous employer, or student, type N/A)*

Date Hired: (if no previous employer, or student, type N/A)*

Address: (if no previous employer, or student, type N/A)*

Phone: (if no previous employer, or student, type N/A)*

Supervisor: (if no previous employer, or student, type N/A)*

Your Title: (if no previous employer, or student, type N/A)*

Personal References (list name, address and phone number of three personal references not related to you that have known you for at least four years):

Name 1: *

Address 1:*

Phone 1:*

Name 2: *

Address 2:*

Phone 2:*

Name 3:*

Address 3:*

Phone 3:*

Emergency Contact Information (Please list the name, address and phone number of someone we may reach on your
behalf in case of an emergency):

Name:*

Address:*

Phone: *

Before checking the box certifying your identity and information released within this form, please ensure that all the information you have disclosed to Jacksonville Public Safety is accurate and truthful. If you are unsure of any question, please make sure that you clarify it with a Public Safety representative prior to signing and submitting this document. Any misrepresentation given by any applicant will result in the denial of the applicant’s request to participate in the Jacksonville Public Safety Citizens Academy. We ask that you provide, without omission whatsoever, any and all information requested. If you should require clarification on any part of this form, please call 910-938-6406 to speak with a Community Services Officer.

I certify that the information given is true and accurate to the best of my knowledge.

By checking this box, I am acknowledging the identifying information within this form is accurate and truthful and is being released to the Jacksonville Police Department for further review.

Date: mm/dd/yyyy*

Release of Information Authorization

I understand that the Jacksonville Police Department will be performing a criminal background and driving history check on me with reference to my application for the Public Safety Citizens Academy. I hereby authorize Jacksonville Public Safety to have access to any and all driving record information and criminal information as it pertains to me. I understand that Jacksonville Public Safety considers any such information confidential and that it will not be released to me. I further authorize the release of any information that is required to clarify my criminal background investigation, be it from any of the following:
• Personal references or any person(s) having knowledge regarding my character or reputation.
• Any past or present employer (to include the U.S. Armed Forces, Maritime Service, Veteran Administration, or U.S. Selective
Service);
• Any Judge, Court or Magistrate.
• Any State, Local or Federal Law Enforcement Agency.
• Any Attorney-at-Law or other legal entity handling any criminal or traffic-related case related to me.
• Any State, Local, City or County Agency
• A photocopy of this release form will be valid as an original thereof, even though the photocopy does not contain my original
signature

I hereby authorize Jacksonville Public Safety to have access to any and all driving record information and criminal information
as it pertains to me. I understand that Jacksonville Public Safety considers any such information confidential and that it will not be released to me.

I further authorize the release of any information that is required to clarify my criminal background investigation.

By checking this box, I authorize release of all information as it pertains to me and as outlined above.

Date: mm/dd/yyyy*