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Full Name <br />�oseville Police Dep�artme�t <br />Citizens' Police Academy <br />Application Form <br />�e Qr� �ar-�P�i � �e rc k eS <br />Address o`? vS"C.o �cv�-e .I Tr�� f'l orl�'t IQ�f_ec1�`��, �'�J/'l :�`���% <br />Home Phone Number �fr ��7' ���� Work Phone Number (o/�- g�U - 7.Sr8� <br />Occupation/Employer <br />Are you a Neighborhood Watch Block Captain � M e m b e r �� <br />Flease explain how you heard of the Citizens' Police Academy & what you expect to learn: <br />..� r�'� � � 6� � i n �ti..� Rot�ru�!/� �J��P . <br />-e�ra� -� wvr�/a' /fk-� � /-��n v�orr �d�fi �o,� r�.� ��/,�c� <br />��c.� ��t�►�^�`" wa�ks c��c� t%� /'01� Q�c✓ �,ci��-,� f i'7` r,�r'o� sr'oeeo � <br />. <br />�' � � �'v�n ,M�n ��y _—lih 4 N�rr� ����lPC�! .� _� 1� m; ��� - �" .�'1.� i ,�,��� <br />G'�l� C�..fj�P C�1 � l��/t%i CfL I/J'-t (.v i Lf "K G �-Pll�A.%7? ..1Lx,/jt9i'C..C-1 �- <br />If you require any special accommodations for the Academy, please list below: <br />� /� <br />��e,��`P-,cpriz� and grant my informed consent to'permit the Roseville Police Department to conduct <br />���:c�a��ainal background check to determine whether I would be ellglb/e to attend the C1tJzens' <br />.�°�cr�i�,� Academy. 1 further understand that 1 will not be accepted as a candidate if 1 have any <br />rlminal record excluding minor traffic offenses. <br />� <br />�ignatur <br />� - lv-�UO� <br />R <br />Return completed form to: <br />Chief Paul Wood <br />Roseville Police Department <br />2660 Civic Center Drive <br />Roseville, Minnesota 55113 <br />