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2. Southern Summit Citizens Police Academy
4. Applicant Information
6. Name
7. Email Address
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. Cellphone Number
18. Are you a citizen of the United States?

    1. Yes
    2. No
19. Have you ever been convicted of a crime?

    1. Yes*
    2. No
21. If yes, explain:
23. Education
25. High School
26. Dates of Attendance
    Dates of Attendance Start Date

    —

    Dates of Attendance End Date
28. Address
30. Degree
31. Did you graduate?

    1. Yes

    1. No
33. College
34. Dates of Attendance
    Dates of Attendance Start Date

    —

    Dates of Attendance End Date
36. Address
38. Degree
39. Did you graduate?

    1. Yes

    1. No
41. Other
42. Date of Attendance
    Date of Attendance Start Date

    —

    Date of Attendance End Date
44. Address
46. Degree
47. Did you graduate?

    1. Yes

    1. No
51. References
    Please list three professional references.
53. Full Name
54. Relationship
56. Company
57. Telephone Number
59. Address
63. Full Name
64. Relationship
66. Company
67. Telephone Number
69. Address
73. Full Name
74. Relationship
76. Company
77. Telephone Number
79. Address
83. Employment
85. Company
86. Telephone Number
88. Address
90. Responsibilities
92. Supervisor
93. May we contact your supervisor for a reference?

    1. Yes

    1. No
95. Disclaimer and Signature
97. Disclaimer and Signature
    All applicants must be at least 18 years of age. A background check will be done on each applicant. The Barberton / Copley / Norton Police Departments reserve the right to deny entry to the Academy based on the findings of a background check.
    
    All the information on the above application is true. I authorize the Barberton / Copley / Norton Police Department to conduct a background check on this application.
99. Signature
100. Date
     Date
Leave This Blank:


102. 1. Receive an email copy of this form.
103. Email address

     This field is not part of the form submission.

104. Submit

* indicates a required field