*Last Name:  

*First Name:  

MI:

*Date of Birth  

*Home Address:  

*Home Phone

Business Phone: Ext.

*Email Address:  

Place of Employment/School:

Employment Address:

*Person to Notify in Case of Emergency  

*Phone:  

*Address:  

During the course of the academy, it is likely that you will encounter physical or emotional stress, and be asked to perform certain physical tasks. Do you have any existing conditions or require and special accommodations that we should know about should you be accepted in the citizens academy?
YesNo
IF YES, PLEASE EXPLAIN:

SUCCESSFUL APPLICANTS WILL BE NOTIFIED OF THEIR ACCEPTANCE. APPLICANTS NOT ACCEPTED FOR THE CURRENT ACADEMY CLASS WILL BE PLACED ON A WAITING LIST FOR THE NEXT CLASS.

AS AN APPLICANT FOR THE OSHKOSH POLICE DEPARTMENT CITIZENS ACADEMY, I CONSENT TO A LAW ENFORCEMENT BACKGROUND CHECK.

 Date:  

Proposing Person: