First Name*

Middle Name*

Last Name*

Street Address*

City*

State*

Zip Code*

Main Phone Number*

Work Phone Number

Optional Phone Number

E-Mail Address

Driver's License Number:*

Date of Birth*

Are you a Neighborhood Watch Block Captain?

Yes

No

Neighborhood Watch Member?

Yes

No

Please explain how you heard of the Citizens' Police Academy and what you expect to learn:*

If you require any special accommodations for the Academy, please list them below:

By typing my full name below, I authorize and grant my informed consent to permit the Roseville Police Department to conduct a criminal background check to determine whether I would be eligible to attend the Citizens' Police Academy. I further understand that I will not be accepted as a candidate if I have any criminal record excluding minor traffic offenses.

Type Full Name*

Today's Date*

Completed applications will be reviewed and applicants will be notified by letter regarding acceptance into the Academy.