(PLEASE PRINT and mail to Natchez Police Department Attn: Captain Tom McGehee, 233 Devereaux Dr, Natchez, MS 39120)

 NAME: _____________________________________________________________________________ D.O.B. ____________________

 ADDRESS: ________________________________________________________________________________________________________________________

 CITY/STATE/ZIP: __________________________________________________________________________________________________________________ 

HOME PHONE: ______________________     WORK PHONE: __________________ OCCUPATION: ________________________

EMPLOYER: _______________________________________________________________________________________________________________________

 DRIVER'S LICENSE: ______________________    SOCIAL SECURITY: ____________________________  

 COMMUNITY/GROUP/ORGANIZATION AFFILIATION (if applicable):

 ______________________________________________________________________________________________________________________________

WHY DO YOU WISH TO ATTEND THE CITIZEN'S ACADEMY? 

  ______________________________________________________________________________________________________________________________

 _______________________________________________________________________________________________________________________________

 ______________________________________________________________________________________________________________________________

 HOW DID YOU HEAR ABOUT THE CITIZEN'S ACADEMY? 

  ______________________________________________________________________________________________________________________________

 _______________________________________________________________________________________________________________________________

 ______________________________________________________________________________________________________________________________

 HAVE YOU EVER BEEN ARRESTED OR CONVICTED OF A CRIME? (if so, please explain)

  ______________________________________________________________________________________________________________________________

 _______________________________________________________________________________________________________________________________

 ______________________________________________________________________________________________________________________________

 GIVE THE NAME/ADDRESS/PHONE NUMBER OF TWO REFERENCES:

1.) _______________________________________________________________________________________________________________________________

 2.) _______________________________________________________________________________________________________________________________

(Mail to: Natchez Police Department, 233 Devereaux Drive, ATTN: Charles Woods, Natchez, MS 39120)

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