LPD Form #309 revised 11/16
Citizens Police Academy Application
La Vergne Police Department
Date: __________________
Name: Mr. Mrs. Ms. _______________________________________________________________
Address: _________________________________________________________________________
City: __________________________State:_____________ Zip:____________________________
Phone: (___)____________ Email:_____________________________________________________
Date of Birth:_____________Drivers License Number__________________ State_______________
Do you have a firearms carry permit? Yes_______ No_______
Why do you wish to attend the Citizens Police Academy? _________________________________
_______________________________________________________________________________
How did you first hear about the Citizens Police Academy? ________________________________
Have you ever been arrested or convicted of a crime?________________ If Yes, please explain.
_______________________________________________________________________________
Give the names and phone numbers of two character references:
1.______________________________________________________________________________
2.______________________________________________________________________________
Throughout the Citizens Police Academy there will be optional activities that involve physical exertion.
Do you believe that you would be able to participate in these if you choose to? ______________
Signature: ___________________________________ Date: ____________________
The Citizens Police Academy is a free 12-week informative program designed to inform citizens of the operations of
the La Vergne Police Department. This program does not certify someone as a police officer and it is not
employment with the City of La Vergne.
Citizens Police Academy Applications may be mailed or delivered to:
La Vergne Police Department
5093 Murfreesboro Road
La Vergne, Tennessee, 37086
This information is necessary to perform a criminal history and background check on all applicants.
The City of La Vergne does not discriminate on the basis of race, sex, color, religion, national origin, age, disability or
veteran status in the provision of services, in programs, activities or employment opportunities and benefits.
The City of La Vergne does not discriminate on the basis of disability in the programs and activities on which it
operates pursuant to the requirements of the Americans With Disabilities Act of 1990, PUB. L. 101-336. This policy extends
to both employment and admission to and participation in the programs, services and activities of the City of La Vergne.
THIS IS NOT AN EMPLOYMENT APPLICATION
click to sign
signature
click to edit
![]()
