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2. Contact Information*
4. First Name
5. Last Name
7. Nickname or Preferred Name:
9. Address1
11. Address2
13. City
14. State
15. Zip
17. Primary Phone Number:
18. Secondary Phone Number:
19. Email Address:
21. Driver's License or ID Card Number:
22. Driver's License or ID Card State:
24. Date of Birth:
26. Your Employer:
27. Your Occupation/Job Title:
29. Have you EVER been arrested (not necessarily convicted) for ANY offense, other than a traffic violation? Driving While Intoxicated (DWI) is NOT considered a traffic violation.
31. Please describe in your own words why you want to be in the Bellaire Citizen's Police Academy?
33. How did you hear about the Bellaire Citizen's Police Academy?
35. By checking this box, you hereby authorize the Bellaire Police Department to make an examination of their records, including a computerized criminal history check, for the purpose of evaluating your application and you further understand that any misrepresentation on this application will be grounds for your rejection to the Citizen's Police Academy.

    1. I agree
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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

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