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2. First Name*
3. Middle Name
4. Last Name*
6. Maiden Name
8. Address*
9. Apt #
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. E-Mail Address*
18. Birthday*

    MM-DD-YYYY

19. Race
20. Gender
22. Drivers License #*
23. Issuing State*
24. Shirt Size*
    -- Select One --Unisex SUnisex MUnisex LUnisex XLUnisex 2XLUnisex 3XLUnisex 4XL
28. Employment
30. Current Employer*
32. Position*
34. Address*
35. City, State, Zip*
39. Education
41. High School*
42. Post-Secondary College/University*
44. Major/Minor
48. Have you ever been arrested?*
    -- Select One --NoYes
49. Have you been convicted of a felony or misdemeanor charge?*
    -- Select One --NoYes
51. Why do you want to participate in the Citizen’s Academy?*
53. How did you hear about the Westfield Police Department Citizen’s Academy?*

    1. City of Westfield Website
    2. Facebook
    3. Officer Referral
    4. Other
54. Officer Name, if referred
55. If other, please explain.
59. Electronic Signature Agreement*

    I have answered all questions fully and truthfully. I understand that any misrepresentation or omission of requested information will eliminate me from consideration as a candidate to participate in the Westfield Police Department’s Citizen’s Academy. I authorize the Westfield Police Department to conduct a background investigation. Your electronic signature below indicates your agreement with the following statements: By typing my name in the following box I certify the above statements to be true and correct, to the best of my knowledge, and that this information can be used solely for the purpose of processing my Citizen’s Academy application.

    1. I agree.
61. Electronic Signature
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field