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2. Last Name*
3. First Name*
4. Middle Name*
6. Street Address*
8. City*
9. State*
10. ZIP Code*
12. Home Phone Number
13. Cell Phone Number*
14. Work Phone Number*
16. Email Address*
18. Employer*
20. What is your perception of the Police Department?*
22. What do you know about the Police Department?*
24. Why do you want to attend the Citizen's Police Academy?*
26. How did you hear about the Citizen's Police Academy?*
28. Race*
    -- Select One --American Indian / Alaska NativeAsianBlack / African AmericanNative Hawaiian / Pacific IslanderWhite / Caucasian

    Choose One
29. Sex*
    -- Select One --FemaleMale

    Choose One
30. Date Of Birth*
32. Social Security Number*
33. Driver's License Number / State*
35. I hereby authorize the Warner Robins Police Department to receive any criminal history record information pertaining to me that may be in the files of any local or state criminal justice agency in Georgia.
37. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
39. Electronic Signature*
40. Date / Time*
    Date / Time

    Date / Time
42. You will be contacted by phone or email for the dates of your class.
44. This form may be printed and mailed or delivered to:
46. Warner Robins Police Department
48. Attn: Officer Greg Martin
50. 100 Watson Blvd.
52. Warner Robins, GA 31093
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54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit Submit and Print

* indicates a required field