City of Mill Creek

PRELIMINARY APPLICATION FORM FOR THE MILL CREEK POLICE CITIZENS ACADEMY

Please complete the following information, All fields are necessary to complete a criminal background check, which is required.

Name - First, Last, Middle Initial:

Physical Address (No PO Boxes):

City:

State:

Zip:

Email:

Daytime Telephone:

Evening Telephone (if different):

Date of Birth:

Gender: MaleFemale 

Race: American Indian - Alaskan NativeAsianBlack-African AmericanHawaiian-Pacific IslanderMultiracialUnknownWhitePlease select one 

Driver's License Number: State:

Instructions: Please answer all the following questions for your registration to be complete.

1. Have you ever received a traffic infraction for a moving violation?    Yes   No

    If Yes, list violations and outcomes:

2. Have you ever been arrested? Yes    No             Convicted of a crime? Yes   No

    If Yes to either, please give date(s), charge(s), and outcome(s):

3. Why would you like to participate in the Mill Creek Police Citizens Academy?

Waiver:

There will be images taken throughout the Police Citizens Academy and affiliated events that may be used for marketing purposes. I grant the City of Mill Creek, its agents and employees the right to take photographs of me and use such photographs of me with our without my name and for any lawful purpose, including for purposes of publicity (e.g., print publications, video, website, advertising, etc.). I release and waive any claims or rights of compensation or ownership regarding such uses. I have read and understand the above:

Name:

Date:

Certification:

I hereby certify that the information I supplied is correct and true. Furthermore, I am fully aware that any falsification of information will prompt my disqualification. I authorize the Mill Creek Police Department and its agents and employees to conduct a review of the records of the Mill Creek Police Department and other law enforcement agencies for the purpose of confirming that I am of good character. I hereby release the City of Mill Creek and all its agents and employees from liability which may arise out of the background investigation and recommendations, including liability from negative recommendation based on erroneous information. 

By typing my name and dating below, I am signing this form electronically.

Applicant's Full Name:

Date: