Name:_______________________________________

Address:_____________________________________

City:__________________, MI Zip:_____________

Phone:________________Date of Birth:___________

Drivers License #:_____________________________

How long have you lived at your address?__________

Why do you wish to attend the Academy?: ________ ______________________________________________________________________________________

List any clubs or organizations that you belong to: ___ ___________________________________________

Current Employer:____________________________

Address:_____________________________________

City:__________________Phone:________________

Supervisor:__________________Hire date:________

Past Employer:_______________________________

Address:____________________________________

City:__________________Phone:________________

Supervisor___________________Hire date:________

Have you ever been fired or asked to resign from any job in the last 5 years? (___)yes (___) no

If yes, please explain: ________________________ ___________________________________________

Name:______________________________________________

Address:____________________________________________

Phone #:____________________________________________

List one immediate family member or close friend that can be contacted in the event of an emergency:

Name:______________________________________________

Address:____________________________________________

Phone #:____________________________________________

Please review your answers carefully and read the statement below before signing this application.

"I hearby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and answers to questions. I understand that any omission or false statements on this application shall be sufficient cause for rejection from the Lansing Citizen Police Academy."

"I further understand that the Lansing Police Department will be conducting a thorough background investigation that may include, but not be limited to, any criminal history, employment history and personal references."

___________________________________________________

Applicant Signature Date

Lt. David Nosotti

Lansing Police Department

120 W. Michigan

Lansing, MI 48933