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2. First Name*
3. Last Name*
4. Middle Initial*
   (If none, enter N/A)
6. Street Number*
7. Street Name*
8. Apt #
10. City
11. State
12. Zip
14. Date of Birth: (MM/DD/YYYY)*
15. Phone Number*
16. Email Address
18. Have you ever been arrested for anything other than a traffic offense?*
    -- Select One --YESNO
20. If you answered YES to the question above, explain date of arrest, reason, and location (Agency that arrested you)
22. Place of Employment
24. Work Phone
26. Occupation
28. CHECK ONE: I affirm that I conform to at least one of the following*

    1. I live in Shorewood
    2. I work in Shorewood
    3. I own property in Shorewood
    4. I am currently a student in a Criminal Justice Program
30. I certify that all statements made on this application are true and complete. I authorize any individual, company, organization or institution to release any and all information concerning statements made by me on this application, and do hereby release all parties and individuals connected therewith from all liabilities for any damages whatsoever incurred in furnishing such information. I agree and understand that any deliberate misstatement or omission of material facts may disqualify me from attending the Citizens’ Police Academy. I understand that participating in the Citizens’ Police Academy, does not qualify me as being a police officer or an employee of the Village of Shorewood. The Shorewood Police Department reserves the right to refuse any applicants from participation in the academy program for any reason including those with criminal records, lengthy police contacts, or who would compromise objectives of the academy by being disruptive. The Shorewood Police Department will not discriminate against applicants based on sex, race, religion, handicap, or sexual orientation.
32. Electronic Signature*

    1. Signature

    By checking this box, you are submitting an electronic signature.
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit Submit and Print

* indicates a required field