Application for Volunteer Participation
Complete and return to:
Dearborn Heights Police Department
Att’n: Sgt. Todd Learst
25637 Michigan Avenue
Dearborn Heights, MI 48125
Name
Last / Family Middle Initial First / Given
Street Address Apt. No.
City State Zip
Telephone Home __ __ __ — __ __ __ — __ __ __ __ Work __ __ __ — __ __ __ — __ __ __ __ ext.
E-mail (required) Fax __ __ __ — __ __ __ — __ __ __ __
Drivers License No. State Date of Birth
Now Employed? □ Yes □ No Company Name
□ Retired Length of Employment
Employment Address
City State Zip
Your Profession / Job Title
Emergency Contact
Name (First & Last) Relationship
__ __ __ — __ __ __ — __ __ __ __ ext. __ __ __ — __ __ __ — __ __ __ __ ext. Emergency Contact Phone Number - Daytime Emergency Contact Phone Number - Evening
PERSONAL REFERENCES
1.
Name (First & Last) Relationship Telephone Number
2.
Name (First & Last) Relationship Telephone Number
3.
Name (First & Last) Relationship Telephone Number
Continued on back
Explain briefly why you wish to participate in the Dearborn Heights Citizens Academy
Please list any associations, clubs or organizations you are actively involved with
Have you ever been arrested for, convicted of, or cited for an offense other than a traffic fine of $200 or more? □ Yes □ No
If “Yes”, please explain in detail, listing dates, charges, locations, and action(s) taken
Do you have any health problems or other circumstances that would limit your participation in this class? □ Yes □ No
If “Yes” please describe briefly
I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and answers to questions. I understand that any omission or false statement(s) on this application shall be sufficient cause for rejection for enrollment or dismissal from the Dearborn Heights Citizens Police Academy.
I further understand that the Dearborn Heights Police Department will be conducting a thorough background investigation that may include, but not be limited to, any criminal history, employment history and personal references.
Signature of Applicant Date
If you have questions regarding the Dearborn Heights Citizens Police Academy, contact Sgt. Todd Learst at the Dearborn Heights Police Department:
(313) 277-7388