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COTTAGE GROVE POLICE DEPARTMENT CITIZEN'S ACADEMY APPLICATION (City of Cottage Grove)

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COTTAGE GROVE POLICE DEPARTMENT
CITIZEN'S ACADEMY APPLICATION
APPLICANT INFORMATION
NAME (LAST, FIRST, FULL MIDDLE, JR/SR): DATE OF BIRTH: HOME PHONE #:
MAIDEN NAME (IF APPLICABLE) OR OTHER NAMES USED: EMAIL ADDRESS:
ADDRESS: CITY: COUNTY: STATE: ZIP CODE:
PLACE OF EMPLOYMENT: JOB TITLE: WORK PHONE #:
LENGTH OF TIME WITH CURRENT EMPLOYER: MN DRIVERS LICENSE OR ID NUMBER:
EMERGENCY CONTACT INFORMATION (OPTIONAL)
NAME (LAST, FIRST, MIDDLE, JR/SR): RELATIONSHIP: TELEPHONE #:
ORGANIZATIONAL ACTIVITIES
Please list any organizations, volunteer activities, or community groups to which you belong:
EXPLAIN WHY YOU ARE INTERESTED IN ATTENDING THE CITIZEN’S ACADEMY
COTTAGE GROVE POLICE DEPARTMENT
CITIZEN'S ACADEMY APPLICATION (cont)
1. Have you ever been arrested? If yes, provide date, crime, location: YES NO
_______________________________________________________________________________________________
2. Have you ever been convicted of a crime? If yes, provide date, crime, location:
YES NO
_______________________________________________________________________________________________
3. Have you ever been fingerprinted? If yes, provide date, location and reason:
YES NO
_______________________________________________________________________________________________
4. Do you have any physical limitations or health conditions we should be aware of?
YES NO
_______________________________________________________________________________________________
DATA PRACTICES ADVISORY
The Minnesota Data Practices Act requires that you be advised of the following information:
As an applicant for the Cottage Grove Police Department’s Citizen's Academy, you are being asked to provide
private and/or confidential data about yourself which will be used to check criminal histories, arrest records and
warrant information to determine your eligibility. (Please note: A criminal record does not automatically
disqualify an applicant.)
You may refuse to provide this information; however should you refuse, the investigation cannot be completed
and will result in your application not being processed. The information that you provide will be used by this
agency to complete its investigation and may be conveyed to other law enforcement agencies.
APPLICANT’S STATEMENT
I hereby certify that I currently either live, work, or own a business in Cottage Grove, St. Paul Park, or Newport
and all answers to the above questions are true. I agree and understand that any false statements contained in
the application may cause rejection of this application. I have read and understand the above Data Practices
Advisory and I agree to allow the Cottage Grove Police Department to run a Criminal Background Check on
me for the purposes of determining my suitability for this program. I understand that I may be disqualified from
the application process if I have a known criminal history, I am the subject of a protective order, or I have an
extensive driving record.
___________________________________________________________ __________________________
A
pplicant’s Signature Date
The City of Cottage Grove considers applicants for all positions without regard to race, color, religion,
sex, national origin, age, sexual orientation, marital or veteran status, the presence of a non-job-related
medical condition or disability, or any other legally protected status. EOE/AA/ADA
FOR DEPARTMENT USE ONLY
MN DRIVER LICENSE PRINTOUT
:
HENNEPIN WARRANTS
:
MINCIS
/
NCIC
:
RAMSEY WARRANTS
:
BCA
:
COTTAGE GROVE RECORDS
:
WASHINGTON WARRANTS
:
BACKGROUND CHECK BY
:
COTTAGE GROVE POLICE DEPARTMENT
CITIZEN'S ACADEMY COMMITMENT
The Cottage Grove Police Department’s Citizen's Academy is an intensive 8-week program.
Classes are scheduled one night a week for eight consecutive weeks. Each class lasts three hours.
Academy staff and instructors are committed to providing all participants information and
understanding of the mission and operation of Cottage Grove's Public Safety Department. Our goal
is to provide:
"UNDERSTANDING THROUGH EDUCATION"
If you are selected to participate in the Citizen's Academy, you will be expected to attend all
eight classes and complete a ride along with a patrol officer.
In order to receive full benefit of the program, it is crucial that you attend every class.
No unauthorized audio taping, videotaping, or photography is permitted during the Academy.
You are not permitted to select a substitute if you are unable to attend any of the classes. Other
applicants have been placed on a waiting list and will be selected to take your place if you find you
are unable to attend the Academy after being selected.
If you are willing to make a commitment and to become an involved citizen, we encourage you to
accept this invitation to apply to attend the Cottage Grove Police Department’s Citizen's Academy. We
need you to help make Cottage Grove a better place in which to live.
Please complete and sign both the APPLICATION and COMMITMENT forms and return to:
COTTAGE GROVE POLICE DEPARTMENT
CITIZEN'S ACADEMY
ATTENTION: Sergeant Brian Franck
12800 Ravine Parkway S.
Cottage Grove, MN 55016
Sub
OR
If selected to participate in the Cottage Grove Police Department’s Citizen's Academy,
I am willing to make the above commitments.
_____________________________________________________ _________________________
Applicant's Signature Date
Submit in person to the COTTAGE GROVE POLICE DEPARTMENT at the above address.
Faxes accepted at 651-458-2820 and emails accepted at bfranck@cottagegrovemn.gov
APPLICATION DEADLINE: to be determined
By participating in the Academy, you grant permission for the City of Cottage Grove and/or
South Washington County Telecommunications Commission on behalf of the City, to take and
use photographs, video and other likenesses of you in City of Cottage Grove promotional
materials and publications.
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COTTAGE GROVE POLICE DEPARTMENT CITIZEN'S ACADEMY APPLICATION (City of Cottage Grove)

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Completed 12 February 2021

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