Please complete this application and email to Your
signature at the bottom authorizes the Chesterfield County Police Department to perform a
background check. Any information that the Chesterfield County Police Department deems
detrimental to the program may disqualify you from participation.
Once accepted into the Academy, applicants will receive a letter of confirmation, additional
information, and directions.
Following successful attendance, the participant will receive a certificate of completion from
the Chief of Police during a graduation ceremony.
Applicants Information
Last Name: First Name: Middle Name:
Address: Date of Birth:
Phone: Home
Alternate Phone: Home
Sex: Male
Email Address: Drivers License
Are you a Chesterfield County resident?
Do you own a business, or are you a member of a community or civic organization in Chesterfield County?
Would you like a free home security assessment?
Which academy would you like to attend?
Participants Signature
I, ___________________, authorize the Chesterfield County Police Department, or its designee, to
obtain the my criminal history and run a DMV check utilizing my name, for purposes of my
application to the CitizensPolice Academy. I agree that my electronic signature is the legal
equivalent of my manual signature for this authorization.
Yes No
Yes No
Yes No
Summer Session 1 - Tuesdays July 21 - Sept. 1, 6-9 p.m.
Summer Session 2 - Thursdays July 23 - Sept. 3, 6-9 p.m.
Fall Session - Thursdays, Sept. 10 - November 12, 6:30 -10 p.m.
Chesterfield County Police Department
Community Services Division
Citizens' Police Academy Coordinator
2730 Hicks Road
N. Chesterfield, VA 23235