WEBSTER POLICE DEPARTMENT

CITIZENS POLICE ACADEMY APPLICATION

2008 Academy

CANDIDATE INFORMATION:

1.                     Name: __________________________________________

2.                     Address:_________________________________________

3.                     Date of Birth:____________ 

4.                     Telephone: ____________        Work: _________________

5.                     Employer Name: __________________________________

Address: _______________________________________

6.                     N.Y.S. Driver’s License #:__________________________

7.                     Due to the nature of the Law Enforcement information that may be disseminated in this Academy, it is necessary to restrict enrollment to only those persons who have never been convicted of a felony or have not been convicted of any crime in the past five years.

I do hereby give my consent to the Webster Police Department to conduct a criminal history clearance on my name and I am furnishing the above information on a voluntary basis with the understanding that it shall be used to perform such clearance.

Signature: _________________________________________

Date: _____________________________________________

***If you have any questions please contact Officer Debra J. Hart 872-1216 ext. 252