APPLICATION FOR
CITIZEN’S POLICE ACADEMY
FLORENCE POLICE DEPARTMENT


Please Complete Every Blank:


NAME  ____________________________________________________________________
			FIRST		MI			LAST

ADDRESS _________________________________________________________________
			BOX OR STREET NUMBER		STREET NAME

	         ________________________________________________________________
			CITY			STATE		ZIP CODE

PHONE  ___________________________ DATE OF BIRTH  ________________________


PLACE OF EMPLOYMENT ___________________________________________________


OCCUPATION  _____________________________________________________________


IF RETIRED, WHERE WERE YOU EMPLOYED? ________________________________

DO YOU KNOW ANY MEMBERS OF THE FLORENCE POLICE DEPARTMENT?  IF SO, 

PLEASE NAME THEM________________________________________________________

IF GIVEN THE OPPORTUNITY, WOULD YOU LIKE TO RIDE ALONG WITH A SWORN 

OFFICER ON PATROL?  ______________________________________________________

DO YOU HAVE A VALID DRIVER’S LICENSE?  IF SO, PLEASE LIST THE STATE AND 

NUMBER.  __________________________________________________________________

	AFTER GIVING THE ABOVE INFORMATION TO THE FLORENCE POLICE 
DEPARTMENT, I NOW AUTHORIZE THE CHIEF OF POLICE OR HIS REPRESENTATIVE 
TO EXAMINE MY RECORDS AND DETERMINE MY ELIGIBILITY TO ATTEND THE 
ACADEMY.


_________________________________                   __________________________________
	SIGNATURE					DATE