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2. Berea Police Department Citizen Academy Application 2022

4. Thank you for applying to the City of Berea Citizen Police Academy class. Return your completed application to the Police Department in person, via US mail, or by email to Ptl. Nick Huskins, Nhuskins@bereapolice.org .     

   To be eligible for the Academy, applicants must:

   • Be 21 years of age or older
   • Have a High School Diploma or GED
   • Be a resident of the City of Berea OR work in the City
   • Have no pending criminal charges
   • Have no felony convictions; misdemeanor convictions will be considered on a case by case basis
   • No pending civil litigation against the City, any other municipality, state, or federal government or other governmental or quasi-governmental agencies
   • Have personal character consistent with community standards.
6. CONTACT INFORMATION:
8. Name*
9. Email Address*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Mobile Phone Number*
18. Date of Birth*
    Date of Birth
20. PREVIOUS ADDRESS (if current address is less than 10 years). Please list dates of residency:
22. 1.) Address
24. City
25. State
26. Zip Code
28. Date you lived at residency
    Date you lived at residency Start Date

    —

    Date you lived at residency End Date
30. 2.) Address
32. City
33. State
34. Zip Code
36. Date you lived at residency:
    Date you lived at residency: Start Date

    —

    Date you lived at residency: End Date
38. 3.) Address
40. City
41. State
42. Zip Code
44. Date you lived at residency:
    Date you lived at residency: Start Date

    —

    Date you lived at residency: End Date
48. EMPLOYER:
50. Company Name
52. Address
54. City
55. State
56. Zip Code
58. Position
59. Period of Employment
61. Name of Supervisor
63. Supervisor Email Address (if known)
64. Supervisor Phone Number
68. EDUCATIONAL BACKGROUND:
70. Name of School
71. Year of Graduation
73. College #1
74. Degree Received/Course of Study
76. Years Attended
78. College #2
79. Degree Received/Course of Study
81. Years Attended
85. REFERENCES:

    Please provide 3 non-relative references.

87. Reference #1
89. Name
90. Phone Number
92. Address
94. City
95. State
96. Zip Code
98. Relationship
99. Years Known
101. Reference #2
103. Name
104. Phone Number
106. Address
108. City
109. State
110. Zip Code
112. Relationship
113. Years Known
115. Reference #3
117. Name
118. Phone Number
120. Address
122. City
123. State
124. Zip Code
126. Relationship
127. Years Known
131. Have you ever been arrested and/or convicted of a crime? Yes / No (circle one)

     1. Yes
     2. No
133. If yes, please explain, including arresting agency, address, and date. Attach additional pages, if necessary:
135. Are you a member of any organizations (i.e. civic clubs, community organizations, block-watch, etc.)?

     1. Yes
     2. No
137. If yes, please list organizations;
139. Why do you wish to attend the Citizen Police Academy?
143. • All applicants meeting the requirements for the Academy will be considered. Class size is limited. The Police Department reserves the right to decline any applicant. 
     • Successful completion of this Academy DOES NOT provide any professional certifications, licenses, or other qualifications.
     • Providing false information on this application will be grounds for non-admittance to or dismissal from the Academy.
145. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 

     1) Your application will not be signed in the sense of a traditional paper document.

     2) By signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature.

     3) You may still be required to provide a traditional signature at a later date.

     4) You give permission to the Berea Police Department to conduct a background check to determine if you have a criminal record and meet the requirements of entry into the City of Berea Citizen Police Academy.

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


149. 1. Receive an email copy of this form.
150. Email address

     This field is not part of the form submission.

151. Submit

* indicates a required field