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A Hennepin County Sheriffs Office <br />CITIZEN LAW ENFORCEMENT ACADEMY <br />Application for Enrollment <br />Name (Last / first / middle)Date of Birth <br />Street Address Home Phone <br />City/Stale/Zip Driven Licence Number <br />Are you a resident of Hennepin County? How long? <br />IBACKGROUND <br />Please explain brief!) why you wish to enroll in the Citizen Law Enforcement Academy, <br />Please list any associations, club.' organizations you belong to or are afllliaicd with. <br />Have you ever been arrested for, convicted of, or cited for an offense other that minor traffic offences? YES___NO____If yes, <br />please explain on back of sheet, list appropriate dates, charges, places and charges. <br />REFERENCES AND EMPLOYMENT <br />Present Employer Supervisor Your title <br />Address Telephone number Date hired <br />Personal Reference Address Telephone <br />Emergency Contact Relationship Telephone <br />•x. <br />Were you recommended or advised to apply for <br />enrollment to the academy? Yes No <br />Ifycs, by w hom? <br />SIGNATURE <br />• I hereby certify that there arc no willful misrepresentations omission or falsifications in the aforementioned statements and answers. <br />I understand that any omission or false statements on this application shall be sufficient cause for rejection for enrollment or <br />dismissal from the Hennepin County Sheriffs Citizen Law Enforcement Academy. I understand there is no charge for the Academy <br />and, if selected for enrollment, pledge the time commitment to attend. I further understand that the Hennepin County Sheriffs <br />Office will conduct a criminal history* and record.s check on all applicants, the results of which could be grounds for mv rejection. <br />Applicant's Signature Date <br />Return completed applications to:Hennepin County Sheriffs Office <br />Citizen Law Enforcement Academy <br />Room 6 Courthouse <br />Minneapolis, MN 55415 <br />For more information call: <br />Captain Jim O'Shea <br />348.7918 <br />All applicants must be 2 hears of age. Incomplete and'orunsignaf applications will not consider^ <br />Received by:Received date: <br />Records check by:Date completed:Recommendation: