First Name*

Middle Name*

Last Name*

Date of Birth*

Home Address*

City*

State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

Zip*

Phone*

E-mail Address*

Business/Occupation*

Drivers License Number*

Drivers License State*

Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMassachusettsMarylandMichiganMinnesotaMississippiMissouriMontanaNorth CarolinaNorth DakotaNebraskaNevada New Hampshire New JerseyNew MexicoNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyomingWashington D.C.

I, the undersigned, hereby grant permission to the Southlake Department of Public Safety to conduct a background investigation on me to determine my eligibility to attend the Southlake DPS Community Emergency Repsonse Team training program, and for no other purpose. I understand that my acceptance is predictated on no felony convicions, no convictions for offenses involving moral turpitude and no outstanding warrants of any kind. I further understand that, should I not qualify for any reason, that all records obtained, collected, or otherwise prepared for this purpose shall be destroyed in their entirety.

Signature*

Date*

Note: Applications will be reviewed and approved in the order they are received. Only 25 positions are avaliable in each class. Applicants who have previously completed the Southlake Citizens' Academy will be given preference to attend, as it relates to class size. Applications not approved due to clas size will be held for the next available class.