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2. 
4. Name*

   First and Last

5. Date of Birth*

   Month-Date-Year

7. Address*

   City, State, Zip

9. Phone Number*
10. Driver's License Number*
12. Employer*
14. Personal Reference*
16. Have you ever been arrested?*

    1. Yes
    2. No
18. If so, please explain:
20. Please describe why you want to attend the Channahon Citizens Police Academy:*
22. How did you hear of this program?*
24. Electronic Signature Agreement*

    The Channahon Citizens Police Academy is open to anybody 18 years of age or older. Channahon residents get first priority. Your signature authorizes the Channahon Police Department to conduct a background investigation and waives liability against the Channahon Police Department and its members. The Channahon Police Department reserves the right to deny entry or seek removal from the program as deemed necessary.

    The information provided through the Village of Channahon Citizens Police Academy is not a substitute for legal or other professional advice where the facts and circumstances warrant. If any participant requires legal advice or professional assistance, they should always consult their legal or other professional advisor and discuss the facts and circumstances that apply.

    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.

    1. I agree.
26. Electronic Signature
27. Date*
    Date
29. 
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field