WORTHINGTON DIVISION OF POLICE
CITIZEN'S ACADEMY APPLICATION FOR ENROLLMENT

Applicants must be 18 years of age to apply and must live or work within the proper of Worthington. However, we also encourage citizens who do not fall in either category and have an interest in law enforcement, to apply. Incomplete and/or unchecked agreement will not be considered.

Date:

Name:*

Home Address:

Home Phone:

Work Phone:

Present Employer:

Work Address:

Occupation & Hire Date:

Date of Birth:

Social Security#:*

Driver's License#:*

Email:

Have you ever been arrested for, convicted of, or cited for an offense other than traffic citations?

Yes

No

If Yes, Explain why you wish to be enrolled in the Worthington Citizen's Police Academy:

Briefly explain why you wish to be enrolled in the Worthington Citizen's Police Academy.

List other community activities that you are involved with:

List two character references who are not family members or employers:

Name:

Address:

Home Phone:

Work Phone:

Name:

Address:

Home Phone:

Work Phone:

Please review your answers carefully and read the statement below before submitting your application.

I hereby certify that there are no willfull falsifications, omissions or misrepresentations in the foregoing statements and answers to the questions.
I consent to, and understand that, the Worthington Police Department will conduct a thorough background investigation on me.

I also understand that any omission or false statement on this application will be sufficient cause for rejection for enrollment or dismissal from the Worthington Citizen’s Police Academy.

I understand the information contained in this application is considered a public record and may be released to the media or others upon their request.

I also understand that I may be photographed or videotaped by the news media or the Worthington Division of Police during the course of this program. These pictures or videotapes will be used for news releases and informational promotions.

Some classes require walking and standing, as different facilities will be used or toured. Please inform us of any considerations or accommodations that you may need while at these facilities.

Submit Application

I Agree

I Disagree