DCCPAA APPLICATION FORM

Name*

First Last

Address*

Street Address Address Line 2 City ZIP / Postal Code

Phone*

DRIVERS LICENSE #*

BIRTH DATE*

SEX*

MALE
FEMALE

Eye Color*

Please select your eye color

Shirt Size*

Please Select your shirt size

EMPLOYER/SCHOOL NAME*

Email*

REFERRAL*

How were you referred to CPA?

Participation*

Why do you want to participate in this class?

MEDICINES*

List any medications and/or allergies we may need to know about: Enter NONE if none.

EMERGENCY CONTACT NAME*

First Last

EMERGENCY CONTACT PHONE*

ARRESTS*

Have you ever been arrested for a felony or are you currently on parole or probation?

NO
YES

(A background check will be conducted on each applicant. Any intentional misrepresentation will be grounds for immediate dismissal.)

AREEST INFORMATION*

Please explain:

I hereby acknowledge that I have completed the above information fully and accurately. I understand and give my permission, with respect to the Centerville Police Department and/or Davis County Sheriff’s Office, to conduct a background investigation to determine my suitability for admission to this program.

SIGNATURE*

Date*
Enter today's date
Date Format: MM slash DD slash YYYY

For more information, please contact Tricia Gallagher at 801-292-8441

DAVIS COUNTY CITIZENS POLICE ACADEMY

DCCPA APPLICATION FORM

Step 1 of 3 - Course Previously Taken