subject_line
First Name
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Last Name
*
Street Address
*
City
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State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
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Email Address
*
Are you 21 years of age or older?
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Yes
No
Do you have a high school diploma, or its equivalent, or have passed the General Education Diploma (GED) test?
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Yes
No
Do you have a drivers license?
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Yes
No
Have you served in the U.S. Armed Forces?
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Yes
No
Do you have any previous experience in Law enforcement and/or Public Safety?
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Yes
No
Have you been convicted of one or more of the following offenses? check all that apply
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A felony
Misdemeanor within five (5) years
Misdemeanor within ten (10) years involving domestic violence
Two or more DWI offenses
No
Are you of good moral character?
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Yes
No
I CERTIFY THAT ALL INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IF I DELIBERATELY CONCEAL OR ENTER FALSE INFORMATION ON THIS FORM, THAT MY NAME MAY BE REMOVED FROM THE ELIGIBLE LIST
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