Email Address*
First Name*
Middle Name (optional)
Last Name*
Street Number & Name*
City*
State*
Zip Code*
Business Name (if applicable)
Business Address (if applicable)
Home Phone
Cell Phone*
Business Phone
Occupation*
Job Title*
Drivers License Number*
Date of birth
Referred By
Have you ever been arrested for any offense other than a traffic violation?*
Yes
No
(if yes, state where, when, and describe the circumstances.)
Describe in your own words why you want to be in the Citizen's Police Academy.*
I hereby authorize the La Grange Police Department to make an examination of their records for the purpose of evaluation by application.*
Yes
No
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