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2. First *
3. Last*
5. Address*
6. Date of Birth*
8. City*
9. State*
10. Zip Code*
12. Employer*
13. Job Title*
15. Employer Address*
16. Email Address*
18. Home Phone *
19. Work Phone*
20. Cell Phone *
22. Driver's License #*
23. State*
24. Expiration Date
26. How did you learn about the Community Policy Academy?*
28. Why are you interested in attending the Community Police Academy?*
30. What do you wish to obtain from attending the Community Police Academy?*
32. What are some issues/concerns related to law enforcement you would like to discuss?*
34. List the area/areas you would like law enforcement to improve.*
36. Your past contacts, if any, with law enforcement have been:*

    1. Positive
    2. Negative
    3. None
38. After participating in the Community Police Academy, would you encourage others to attend? Why or why not?*
40. Consent*

    I consent to a record check to determine eligibility for admittance into the Inglewood Police Department Community Police Academy. If accepted as a student, I agree to abide by all the rules and regulations and refrain from being absent more than once during the ten-week class schedule. Persons selected to attend will be notified by email and/or phone at least two weeks prior to the beginning of class.

    1. I agree
42. 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.
44. Electronic Signature
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field