Auxiliary Police Application

Your Name (First, Middle, Last) (required)

Your Date of Birth (required) (mm/yyyy)

Your Address (required)

Your City State Zip (required)

Your Phone Number (required)

Your Email (required)

US Citizen: (required)
YESNO

Your Drivers License Number (required)

Your Drivers License State (required)

Has your Drivers License ever been suspended? YESNO If yes please explain:(required)

Have you ever been arrested, convicted of, or cited for an offense other than traffic? YESNO If yes, please explain (required)

U.S. Armed Forces Service: YESNO
Branch From (mm/yyyy): To (mm/yyyy):
Type of Discharge:

Are you physically able, without accommodation, to perform all the essential functions of an Auxiliary Police Officer? YESNO If no, please explain: (required)

References (other than employers or relatives):
Please list at least three: Name, Address and Phone #
I certify that the statements made by me in this application are true, complete and correct to the best of my knowledge:
Digital Signature (required)

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