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2. Application for Citizen's Academy Enrollment
4. First Name*
5. Last Name*
7. Home Address (including City & State)*
9. Cell Number*
10. Work Number
12. Date of Birth*

    Your driver's license number may be requested in person at a later date.

13. Email Address*
15. Present Employer*
16. Employer's Email Address*
18. Emergency Contact*
19. Emergency Contact Phone*
21. Personal Reference
23. Name*
25. Relationship*
26. Telephone*
28. Address*

30. I hereby authorize the Bluffdale Police Department to conduct a preliminary background investigation into my character and any personal criminal activity.  I realize that a prior criminal conviction may or may not necessarily disqualify me for admittance into the academy. 

32. Signatue*
33. Date*
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field