Citizens Academy Application -

Date

Nickname

Maiden Name

Legal Name: Last

First

Middle

Gender

Address

Address Line 1

City

State

Zip Code

Residency

Full-time Lee County Resident
Part-time Lee County Resident

Date of Birth

Social Security Number

Home Phone

Cell

Email address

Place of Employment

Title/Position

Emergency Contact

Phone #

Have you ever been arrested? If yes, list the jurisdiction where arrested and the charge:

Have you ever used an alias? Please list all aliases:

Do you have friends in law enforcement? Please give their name and agency:

I was referred by:

Can you attend this Academy without accommodations? If not, what type of accommodation is needed?

All applicants are subject to a criminal background check. I certify that all statements are true and correct to the best of my knowledge and that my application may be rejected for any reason.

Signature of applicant

Clear Signature