Home Address: ________________________________________________________ How Long in Odessa? __________
                               (Street)                  (City)                           (State)          (Zip)

Previous Address (if less than 5 years at above): __________________________________________________________
                                                                                        (Street)              (City)                                (State)              (Zip)

Business Name: _______________________________________Bus. Address: __________________________________

Home Phone: _______________________ Work Phone: _______________________ Sex: ____________ Race: ______

Date of Birth: _______________ Driver's License Number: _____________________ Occupation: ________________

Why do you wish to attend the Citizen Police Academy?

___________________________________________________________________________________________________

___________________________________________________________________________________________________

How did you first hear about the Citizen Police Academy?

___________________________________________________________________________________________________

Have you been arrested or convicted of a crime in the past 5 years? If so, explain:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Give the Name, address & phone number of two character references:

1. __________________________________ _______________________________ _______________________________

2. __________________________________ _______________________________ _______________________________

In consideration of my application to attend the Citizen Police Aademy, I give the Odessa Police Department
Permission to conduct background checks as necessary. I understand that the Odessa Police Department reserves
the right to refuse admission to any applicant.

                                                                                                                                        ______________________________
                                                                                                                                                   Signature of Applicant