Please provide the following information:

 

Name: Last, First, Full Middle:
Other names used, including nicknames & maiden names:
Date of Birth:
Place of Birth:
Current Age:
Gender:	Male Female
Social Security Number:
Hair & Eye Color:
Driver's License Number:
Citizenship (Country)
Acquired by:	Birth Marriage Naturalization
Current Address:
City / State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
E-mail (*required):
Emergency Contact Person:
Relationship:
Phone:
Current Employer:
Business Address:
Job Title:
How long with employer:

Have you ever been charged with a felony offense?

No Yes

Have you ever been convicted of a felony?

No Yes

If yes, list details pertaining to conviction, including date, place, law enforcement agency, charge, court and disposition:

List any civic organization involvements:

Why do you want to attend the Citizen's Police Academy?

By clicking "Submit Form" you authorize the Kenner Police Department to conduct a criminal records check and other investigatory procedures for the purpose of evaluating this application.