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2. Full Name*
3. Email Address*
5. Address*
7. City*
8. State*
9. Zipcode*
11. Phone Number *
12. Best Time To Contact*
    -- Select One --Morning 8 a.m. - 12 p.m. Afternoon 12 p.m. - 4 p.m.Evening 4 p.m. - 8 p.m.Anytime
13. Drivers License Number*
15. Occupation/ Special Interest
17. Why Do You Wish To Attend the Citizen's Police Academy?*
19. Any Dietary Restrictions?
21. Electronic Signature Agrement *

    1. I agree

    By checking the "I agree" box below, you agree and acknowledge that 1) you do hereby authorize the Lebanon Police Department to check your criminal history record in the process of your application. 2) your application will not be signed in the sense of a traditional paper document, 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, and 3) you may still be required to provide a traditional signature at a later date.

23. Electronic Signature*
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field