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2. Last Name*
3. First Name*
4. Middle Name
6. Sex*

   1. Male
   2. Female
7. DOB*
8. SSN*
10. Address*
11. City*
12. State*
14. Primary Phone*
15. Work Phone
16. Secondary Phone
18. Email Address*
19. Driver's License Number*
21. Employer
22. Occupation
24. Employer's Address
25. Supervisor
27. How long have you lived in Urbandale?*
29. Have you ever been arrested for any offense other than a simple misdemeanor?*

    1. Yes
    2. No
31. Will you be able to commit to 10 out of the 12 class sessions?*

    1. Yes
    2. No
33. Polo Shirt Size*

    1. Small
    2. Medium
    3. Large
    4. X-Large
    5. 2X-Large
35. Emergency Contact*
36. Primary Phone*
37. Alternate Phone
41. Please read the following:
    This information is necessary to complete backgrounds on our students and will be kept by the Support Services Commander or a designee for emergency contact. I hereby certify that the information contained in this application is true and complete to the best of my knowledge. You are hereby authorized to make an investigation of my personal history deemed necessary for consideration to attend the Urbandale Citizen's Police Academy.
43. Signature*
    I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. By typing my name above, I am electronically signing my application.
44. Date*
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field