Last name *

First *

Middle

Address *

Home phone *

Work phone *

Your Occupation *

Business address *

Drivers License #

Date of birth *

How did you hear about the academy?

Why do you want to attend? *

Are you involved in any community or civic organizations? Please explain: *

Emergency contact: Name *

Telephone *

Criminal History: Have you ever been convicted of a crime? If yes, please explain

I understand that the St. Helens Police Department will conduct a criminal background check on me, and that information revealed during that investigation may cause me to be excluded from the class . *

• YES
• NO