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2. The Citizens Police Academy is a free 12-week informative program designed to inform citizens of the operations of the La Vergne Police Department. This program does not certify someone as a police officer and it is not employment with the City of La Vergne.
3. Application Date:*
   Application Date:
5. First Name*
6. Last Name*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Email Address*
17. Drivers License Number*
18. State Issued*
19. Date of Birth*
    Date of Birth
21. Do you have a firearms carry permit?*
    -- Select One --YesNo
23. Why do you wish to attend the Citizens Police Academy?*
25. How did you first hear about the Citizens Police Academy?*
27. Have you ever been arrested or convicted of a crime?*
    -- Select One --YesNo
28. If yes, please explain:*
30. Please provide names and phone numbers of two character references
32. First Name*
33. Last Name*
34. Phone Number*
36. First Name*
37. Last Name*
38. Phone Number*
40. Throughout the Citizens Police Academy there will be optional activities that involve physical exertion. Do you believe that you would be able to participate in these if you choose to? *
    -- Select One --YesNo
42. This information is necessary to perform a criminal history and background check on all applicants.
44. The City of La Vergne does not discriminate on the basis of race, sex, color, religion, national origin, age, disability or veteran status in the provision of services, in programs, activities or employment opportunities and benefits.
46. The City of La Vergne does not discriminate on the basis of disability in the programs and activities on which it operates pursuant to the requirements of the Americans With Disabilities Act of 1990, PUB. L. 101-336. This policy extends to both employment and admission to and participation in the programs, services and activities of the City of La Vergne.
48. THIS IS NOT AN EMPLOYMENT APPLICATION
50. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
52. Electronic Signature*
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field