Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastPhone Number *Email Address *Address *City *State *Race *Sex *MaleFemaleDate of Birth (MM/DD/YY) *Age *Zip Code *Driver's License or Identification Number *Columbus County Resident? *YesNoHighest Level of Education *Post GraduateCollege GraduateHigh School DiplomaGEDOtherName of Institution of Highest Education Level *Place of Employment * traffic Phone Level Employment Address *Immediate Supervisor's Name *Immediate Supervisor's Phone Number *Have you been fired or asked to resign from any job in the last five years? *YesNoIf yes, please explain…Emergency Contact Name *Emergency Contact Phone Number *Emergency Contact Address *Please explain why you wish to enroll in the Columbus County Police Citizen's Police Academy *Session Preference *Fall: September – November (10 weeks)Spring: February – April (10 weeks)Summer: July (Monday-Friday/2 weeks)**Participants will receive a certificate upon completion**Do you have any special needs that would require special accommodation in order to participate in this program? *YesNoIf yes, please explain…Have you ever been arrested for, convicted of, cited for an offense (including DWI), other than traffic fines of $200 or less? *YesNo ***A thorough background check will be conducted to determine suitability for admission to the program***If yes, please explain…Submit application now
