Fillable Cadet Application For The Municipal Police Academy (Montgomery County Community College)

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Cadet Application For The Municipal Police Academy (Montgomery County Community College)

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Municipal

Police

Academy

Cadet Application

Municipal Police Academy

340 DeKalb Pk. HSC 1700 Suite Police Academy / Police In-Service

Blue Bell, PA 19422 215 641- 6511 Fax: 215 619-7176

Dear Applicant,

In response to your inquiry regarding the MCCC Municipal Police Academy Program,

we are providing you with the following information outlining our entry requirements and

selection process:

Admission

Admission to the MCCC Municipal Police Academy involves a competitive process that

measures the ability and pre-disposition of an applicant to successfully complete our Municipal

Police Officers’ Education and Training Commission-approved program and become a viable

candidate for a career in law enforcement.

Applicants, please submit your application ASAP because acceptance is on a first come

first served basis and classes fill to capacity quickly. If you wait until the deadline date you may

have to re-apply for the next available class.

No applications will be accepted after the deadline.

Minimum Entry Requirements

All applicants must:

Be a US Citizen

Be at least 20 years of age at the time of submitting an application

Possess a high school diploma or GED certification

Possess a current and valid driver’s license

Provide all documentation outlined on pgs. 3 & 4.

Obtain a psychological exam as indicated on pg. 4 number 14.

MONTGOMERY COUNTY COMMUNITY

COLLEGE MUNICIPAL POLICE ACADEMY

All forms must be dated within six months of the start of class. Application will be

returned if any materials or forms are missing, or incorrect. Please fill out all forms,

listed below, with application printed single sided, and return to:

Montgomery County Community College

Municipal Police Academy

340 DeKalb Pike HSC

Blue Bell, PA 19422

Non-Refundable Application Fee Form - $50 fee using a credit card, money order or check made out

to MCCC.

Pre-Service Application – Read and carefully complete the enclosed application forms. Please print or

type all applicable information.

Copy of High School Diploma or GED. (A copy of an unofficial transcript is acceptable if copy of

diploma is unavailable.)

Copy of Birth Certificate or Passport

Copy of Valid Driver’s License and PA Individual Driver's History (or State in which you are

licensed.) Use the following the link for PA driver history: https://apps.pa.egov.com/IDR/Account/Login

Copy of DD214 (applies only to Military Veterans)

Firearms Training Questionnaire – Carefully read and answer all the questions contained on this form.

State and Federal firearms laws establish eligibility for individuals to own, possess, or control a firearm.

Convictions for certain offenses as listed on this form, as well as other disqualifying conditions also

noted, would prohibit an individual from using a firearm and participating in the firearms portion of the

police cadet training program (Act 120), or from ever being certified by the Municipal Police Officers’

Education and Training Commission as a police officer. Please sign form after answering all questions.

PA Criminal Background Check –Online by accessing: https://epatch.state.pa.us Cost is $ 22 with a

credit card. Select “Submit a New Record Check” NOT “New Record Check” (Volunteers only). On

Requestor page select OTHER as Reason for Request. This method will give you immediate results.

Please print and submit “Response for Criminal Record Check”, not “Invoice for Criminal Record

Check”. Form must be dated within six months of the start of class, with seal in background. If you have

lived in another state, over the age of 18, you will need to submit additional backgrounds from that/those

state/states.

Physical Examination Form – Must be filled out by PA Licensed Physician, Physician Assistant, or

Nurse Practitioner. (Applicant is not to fill out the medical portion). Physician must sign and date

“Professional Opinion” section where indicated on form. Exam should include Five Panel Drug

Urinalysis ordered by the Physician. Drug screening results must be submitted with the application. Both

forms must be dated within six months of the start of class. Applicants must sign and date “Release of

Physical Information” portion on form. Physician may fill in uncorrected vision on Physical Exam form,

if applicant does not wear corrective lenses.

10.

Vision Examination Form - If the applicant wears corrective lenses, both uncorrected and corrected

vision must be filled in by Optometrist/Ophthalmologist, signed and dated, on the Vision Examination

form. If applicant’s uncorrected vision does not fall within the requirements of MPOETC, applicant will

need to get Lasik correction before the start of class. A Physician may fill in uncorrected vision on

Physical Exam form, if applicant does not wear corrective lenses. Form must be dated within six months

of the start of class.

11.

Informed Consent Release Form – Carefully read and sign the enclosed Consent and Release Form.

12.

Driver’s License Information – complete and sign

13.

MCCC Refund Form – Read and sign

14.

Psychological Test – Please contact Dr. John Fraunces at 610 272-4994, to set up your MMPI

Psychological Exam with Interview. His office is located at the Montgomery County Public Safety

Campus (Fire Academy) 1175 Conshohocken Rd., PA 19428. You will need to bring a check for

$160 to your appointment. The Psychologist will send the results directly to the academy. Please

schedule your appointment at least three weeks before the submission deadline, so our office can

receive your results in time. Be advised that the Doctor’s schedule may be filled towards the end

of the application deadline.

15.

Enclose 2, (two) 9 ¼ X 4, Self-Addressed, stamped envelopes

16.

One 2x2 photo, with last name printed on back

If any items are missing or forms are incorrect, your application will be returned.

Applications received after the deadline will be returned.

MONTGOMERY COUNTY COMMUNITY

COLLEGE MUNICIPAL POLICE ACADEMY

Police Academy Pre-Entrance Testing Process

You will be notified by mail, of your Pre-Entrance testing date, which includes the Reading

Comprehension Test and the Physical Fitness Test. If you do not enclose the (2) self-addressed envelopes with

your application, you will not be notified of the Pre Entrance testing. Please pack snacks and sports drinks or

water, and wear PT clothes. There is a $50.00 non-refundable testing fee that will be collected on the day of

the test. Payment must be made by check or money order, payable to MCCC. NO CASH WILL BE

ACCEPTED.

Reading Comprehension Test -This test consists of a multiple choice Nelson Denny Reading

and Comprehension test which will last approximately one hour. Applicant must demonstrate the

ability to read at a minimum 9

grade level.

Physical Fitness Pre-Test –

All applicants must pass, to the 30

percentile (Cooper Standards) listed

events. This test consists of: a 300- meter dash, 1 repetition bench press, 1 minute sit-ups, and a 1.5 mile run.

The tested areas are timed and are gender/age-adjusted. The fitness test requirements are listed on page 19, the

last page of this application. Applicants must receive a passing score in each of the four tested areas.

Interview – After you have forwarded all required materials to the academy, passed the fitness,

reading, and psychological tests, we will contact you to arrange for your interview with the Police Academy

Assessment Board. Please dress appropriately.

Tuition and other Academy Expenses-Tuition for the Police Academy is $ 5,995.00. Cadet uniforms,

PT uniforms, and equipment, will run approximately $500.00. Information on registering for the class and

ordering uniforms will be given at your interview.

MONTGOMERY COUNTY COMMUNITY COLLEGE PUBLIC SERVICES

POLICE ACADEMY APPLICATION FEE FORM

Please Print

Last Name First Name Middle Initial

Social Security Number Birth Date

Home Address

City State Zip Code

County Township

Home Phone Work Phone

Cell Phone E-Mail Address

Employer Job Title

Employer Address

City State Zip Code

Gender Male Ethnicity Hispanic/Latino Race American/Alaska Native Asian

Female Non-Hispanic/Latino Black or African American White

Hawaiian/Pacific Islander

FINANCIAL INFORMATION

Do you plan on using Financial Aid for this program? Yes No

Have you submitted the Free Application for Federal Student Aid (FAFSA)? Yes No

PAYMENT INFORMATION

$50.00 Application Fee

No Cash Accepted

Check Money Order Employee/EmployeeDependent

Sponsored by

Credit Card (please circle): American Express Visa MasterCard Discover

Credit Card # Exp. Date

Security Code

Cardholder’s Signature

None

Non Active or In Training

Active Duty

Veteran

Military Status

Yes

Waive Application Fee, e.g. Sponsored Student:

12/ /20

Exempt from Pre-Test(s) (please circle): MPT.PF (Physical Fitness) MPT.PSY (Psychological)

MCCC Public Services Office Use Only

Program Code : LLMPT 6300

Year:

2020 Term: 03

Start Date: 7/ /20 End Date:

MPT.F (Full-Time)

Section: 2

Processed By

(please

initial)

MONTGOMERY COUNTY COMMUNITY COLLEGE

MUNICIPAL POLICE ACADEMY

PRE-SERVICE CADET APPLICATION

ACT 120

BASIC MUNICIPAL POLICE TRAINING COURSE

Applications accepted between 1/1/20 –3/1/20

No Applications will be accepted after 3/1/20

Date of Birth: Age:

State: Zip Code:

Secondary Phone:

No If yes, where?

Eye Color: Hair Color:

Application for July 2020

Name:

Email Address:

Social Security #:

Home Address:

City:

Primary Phone:

Lived in another state after age 18? Yes

Are you a U.S. Citizen: Yes

Height: Weight:

Driver’s License Information:

State: OLN # Expiration:

High School: Year Graduated:

City: State: Zip Code:

GED: Yes

College: Associates Bachelors Masters

Military Service: Yes No Branch:

Type of Discharge: Date:

Law Enforcement Experience: Yes

No If yes explain:

EMPLOYMENT HISTORY

(Last 10 years)

Employer From To Duties Reason for Leaving

Have you ever applied to, or attended any police academy? Yes No

If yes, list academies below, date, and reason for not attending or completing:

I, (print name) swear or affirm that the information listed on this

application is true and correct. I give permission to any person acting on behalf of the Municipal Police Academy to verify this

information. I understand and agree that if any falsification or omission of fact is found, it may be the basis for denial of

acceptance into the course, or removal from the course. I agree to abide by the Rules and Regulations of the Municipal Police

Academy. I also agree to conform to proper conduct, both in and out of the classroom. I understand and agree that my failure

to do so may result in my removal from the course.

Applicant’s Signature Date

All items on this application must be completed. Applications with blank items will be returned and may result in

your non-acceptance in the course of study. Please type or print legibly.

MONTGOMERY COUNTY COMMUNITY COLLEGE

MUNICIPAL POLICE ACADEMY

FIREARMS TRAINING QUESTIONNAIRE

LAST NAME FIRST NAME MIDDLE INITIAL

SOCIAL SECURITY NUMBER DATE OF BIRTH

DRIVER'S LICENSE NUMBER STATE

( ) ( )

HOME PHONE NUMBER WORK PHONE NUMBER

RESPONSES TO THE FOLLOWING QUESTIONS WILL DETERMINE AN INDIVIDUAL'S ELIGIBILITY TO CARRY A FIREARM AND OBTAIN

CERTIFICATION. COMPLETE THIS PAGE ONLY WHEN USING THIS FORM FOR CERTIFICATION. THIS PORTION OF THE CHANGE OF STATUS

MUST BE COMPLETED AND SIGNED BY THE APPLICANT.

HAVE YOU EVER BEEN ARRESTED OR CHARGED WITH A VIOLATION OF THE LAW?

YES N0

IF YES, EXPLAIN BELOW AND INDICATE ALL ARRESTS AND CITATIONS, INCLUDING TRAFFIC

VIOLATIONS, AND DISPOSITIONS. (CITATIONS FOR ILLEGAL PARKING MAY BE OMITTED.)

DATE

LOCATION

CHARGE

DISPOSITION

HAVE YOU EVER BEEN CONVICTED OF A CRIME ENUMERATED IN THE PENNSYLVANIA UNIFORM YES NO

FIREARMS ACT, § 6105(b)? (CRIMES LISTED UNDER § 6105 APPEAR ON NEXT PAGE.)

HAVE YOU EVER BEEN CONVICTED OF AN OFFENSE UNDER THE ACT OF APRIL 14, 1972 (P.L. 233, NO. 64) YES NO

KNOWN AS THE CONTROLLED SUBSTANCE DRUG DEVICE AND COSMETIC ACT THAT MAY BE

PUNISHABLE BY A TERM OF IMPRISONMENT EXCEEDING TWO YEARS?

ARE YOU AN INDIVIDUAL WHO HAS BEEN ADJUDICATED DELINQUENT BY ANY COURT FOR A CRIME YES NO

WHICH, IF COMMITTED BY AN ADULT, WOULD CONSTITUTE ONE OF THE CRIMES CODE SECTIONS

PRECEDED BY AN ASTERICK (*) ON THE FOLLOWING PAGE IN § 6105 (b)?

ARE YOU AN INDIVIDUAL WHO HAS BEEN ADJUDICATED DELINQUENT BY ANY COURT, AS A

YES

RESULT OF CONDUCT WHICH WOULD CONSTITUTE AN OFFENSE ENUMERATED UNDER

§ 6106(b) OF THE PENNSYLVANIA UNIFORM FIREARMS ACT?

HAS IT BEEN 15 YEARS SINCE THE DELINQUENT ADJUDICATION?

YES

ARE YOU 30 YEARS OF AGE OR OLDER

YES

5. ARE YOU A UNITED STATES CITIZEN? IF NO, ENTER IMMIGRATION IDENTIFICATION NO.

YES

6: ARE YOU SUBJECT TO AN ACTIVE PROTECTION FROM ABUSE ORDER, WHICH PROVIDES FOR T

CONFISCATION OF FIREARMS DURING THE PERIOD OF TIME THE ORDER IS IN EFFECT?

YES

7. HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR CRIME OF DOMESTIC VIOLENCE? THE

YES

CONVICTION MUST BE FOR A MISDEMEANOR-GRADED OFFENSE AND HAVE, AS AN ELEMENT, THE USE OR

ATTEMPTED USE OF PHYSICAL FORCE, OR THE THREATENED USE OF A DEADLY WEAPON, COMMITTED BY A

CURRENT OR FORMER SPOUSE, PARENT, OR GUARDIAN OF THE VICTIM, BY A PERSON WITH WHOM THE VICTIM

SHARES A CHILD IN COMMON, BY A PERSON WHO IS COHABITING WITH OR HAS COHABITED WITH THE VICTIM

AS A SPOUSE, PARENT, OR GUARDIAN, OR BY A PERSON SIMILARLY SITUATED TO A SPOUSE, PARENT, OR

GUARDIAN, OR BY A PERSON SIMILARLY SITUATED TO A SPOUSE, PARENT, OR GUARDIAN OF THE VICTIM.

8. ARE YOU A FUGITIVE FROM JUSTICE?

YES

9. HAVE YOU EVER BEEN ADJUDICATED AS AN INCOMPETENT OR BEEN INVOLUNTARILY COMMITTED TO

YES

A MENTAL INSTITUTION FOR INPATIENT CARE AND TREATMENT UNDER § 302, 303, OR 304 OF THE

PENNSYLVANIA MENTAL HEALTH PROCEDURES ACT (THE ACT OF JULY 9, 1976, P.L. 617, NO. 43)?

PA C.S.A

§ 908

PROHIBITED OFFENSIVE WEAPONS

§ 3701 ROBBERY

§ 911

CORRUPT ORGANIZATIONS

§ 3702 ROBBERY OF MOTOR VEHICLE

§ 912

POSSESSION OF WEAPON ON SCHOOL PROPERTY

§ 3921 THEFT BY UNLAWFUL TAKING OR DISPOSITION, UPON

§ 2502

MURDER

CONVICTION OF THE SECOND FELONY OFFENSE

§ 2503

VOLUNTARY MANSLAUGHTER

'§ 3923 THEFT BY EXTORTION, WHEN THE OFFENSE IS

§ 2504

INVOLUNTARY MANSLAUGHTER, IF OFFENSE IS BASED

ACCOMPANIED BY THREATS OF VIOLENCE

§ 2702

ON THE RECKLESS USE OF A FIREARM

AGGRAVATED ASSAULT

§ 3925 RECEIVING STOLEN PROPERTY, UPON CONVICTION OF

THE SECOND FELONY OFFENSE

§ 2703

ASSAULT BY PRISONER

§ 4912 IMPERSONATING A PUBLIC SERVANT, IF THE PERSON IS

§ 2704

ASSAULT BY LIFE PRISONER

IMPERSONATING A LAW ENFORCEMENT OFFICER

§ 2709

HARASSMENT AND STALKING, IF THE OFFENSE RELATES

TO STALKING

§ 4952 INTIMIDATION OF WITNESSES OR VICTIMS

§ 4953 RETALIATION AGAINST WITNESS OR VICTIM

§ 2901

KIDNAPPING

§ 5121 ESCAPE

§ 2902

UNLAWFUL RESTRAINT

§ 5122 WEAPONS OR IMPLEMENTS FOR ESCAPE

§ 2910

§ 3121

LURING A CHILD INTO A MOTOR VEHICLE

RAPE

§ 5501 RIOT, IF THE OFFENSE RELATES TO A FIREARM OR

OTHER DEADLY WEAON

§ 3123

INVOLUNTARY DEVIATE SEXUAL INTERCOURSE

§ 5515 PROHIBITING OFPARAMILITARY TRAINING

§ 3125

AGGRAVATED INDECENT ASSAULT

§ 6110.1 POSSESSION OF FIREARMS

§ 3301

ARSON AND RELATED OFFENSES

§ 6301 CORRUPTION OF MINORS

§ 3302

CAUSING OR RISKING CATASTROPHE

§ 6302 SALE OR LEASE OF WEAPONS AND EXPLOSIVES

§ 3502

BURGLARY

§ 3503

CRIMINAL TRESPASS, IF THE OFFENSE IS GRADED A

FELONY OF THE SECOND DEGREE OR HIGHER

*ANY OFFENSES EQUIVALENT TO ANY OF THE ABOVE-ENUMERATED OFFENSES UNDER THE PRIOR LAWS OF THIS COMMONWEALTH, OR ANY

OFFENSE EQUIVALENT TO ANY OF THE ABOVE-ENUMERATED OFFENSES UNDER THE STATUTES OF ANY OTHER STATE OR OF THE UNITED

STATES.

DATE

SIGNATURE OF APPLICANT

75 PA C.SA.

"§ 3731 DRIVING UNDER THE INFLUENCE OF ALCOHOL OR CONTROLLED SUBSTANCE

"THREE OR MORE CONVICTIONS IN LESS THAN FIVE YEARS.

I HEREBY CERTIFY THIS FORM CONTAINS NO MISREPRESENTATION OR FALSIFICATION, OMISSIONS OR CONCEALMENT OF MATERIAL FACT AND

THAT THE INFORMATION GIVEN IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND THAT I AM SIGNING THIS

DOCUMENT WITH THE FULL UNDERSTANDING THAT ANY FALSE INFORMATION OR STATEMENT WILL SUBJECT ME TO THE CRIMINAL PENALTIES

OF 18 PA C.S.A. § 4904, RELATING TO UNSWORN FALSIFICATION TO AUTHORITIES, AND COULD RESULT IN PERMANENT DISQUALIFICATION AS

A MUNICIPAL POLICE OFFICER.

§ 6105(a):

PROHIBITS PERSONS CONVICTED OF ANY OF THE FOLLOWING OFFENSES UNDER 18 P.A.C.S. FROM POSSESSIONS, USING, CONTROLLING,

TRANSFERRING, MANUFACTURING, OR OBTAINING A LICENSE TO POSSESS, USE, CONTROL, TRANSFER, OR MANUFACTURE A FIREARM IN THE

COMMONWEALTH OF PENNSYLVANIA. A CONVICTION INCLUDES A FINDING OF GUILTY OR THE ENTERING OF A PLEA OF GUILTY OR NOLO

CONTENDERE, WHETHER OR NOT JUDGEMENT HAS BEEN IMPOSED, AS DETERMINED BY THE LAW OF THE JURISDICTION IN WHICH THE

PROSECUTION WAS HELD. THE TERM DOES NOT INCLUDE A CONVICTION WHICH HAS BEEN EXPUNGED OR OVERTURNED OR FOR WHICH AN

INDIVIDUAL HAS BEEN PARDONED UNLESS THE PARDON EXPRESSLY PROVIDES THAT THE INDIVIDUAL MAY NOT POSSESS OR TRANSPORT

FIREARMS.

MPO-210 (3/2018) SUPERCEDES ALL PREVIOUS VERSIONS OF THE MUNICIPAL POLICE OFFICER PHYSICAL EXAMINATION FORM.

MUNICIPAL POLICE OFFICERS’ EDUCATION AND TRAINING COMMISSION

8002 Bretz Drive

Harrisburg, Pennsylvania 17112-9748

http://www.psp.pa.gov/MPOETC

PHYSICAL EXAMINATION

This form is to be used by both municipal police officer applicants and police academy cadet applicants.

NOTICE AND INSTRUCTIONS TO EXAMINING PHYSICIAN

THIS EXAMINATION MUST BE ADMINISTERED BY A LICENSED PHYSICIAN, PHYSICIAN’S ASSISTANT, OR CERTIFIED NURSE PRACTITIONER

WHO IS LICENSED IN PENNSYLVANIA. THIS EXAMINATION IS TO DETERMINE THE PHYSICAL FITNESS OF THE APPLICANT TO BE

CERTIFIED AS A POLICE OFFICER IN PENNSYLVANIA. THE APPLICANT WHO YOU ARE ABOUT TO EXAMINE IS APPLYING FOR

CERTIFICATION AND WILL BE VESTED WITH A POSITION OF PUBLIC TRUST. HE/SHE MAY, AT SOME FUTURE TIME, BE REQUIRED TO

EXERCISE SIGNIFICANT PHYSICAL STRENGTH AND UNDERGO HIGH EMOTIONAL STRESS.

LAST NAME

FIRST NAME

MIDDLE INITIAL

STREET ADDRESS

CITY/BORO

STATE

ZIP CODE

SOCIAL SECURITY NUMBER

DATE OF BIRTH

GENDER

DATE OF EXAM

OVERALL FITNESS

Is the applicant’s physical condition such that the applicant can reasonably be expected to withstand significant cardiovascu lar stress? This includes

normal function of the heart, lungs, blood pressure, etc. YES NO

Is the applicant free from any debilitating conditions such as tremor, incoordination, convulsion, fainting episodes, or other neurological conditions

which may affect the applicant’s ability to perform as a police officer? YES NO

Is the applicant free from any other significant physical limitations or disability which would, in the physician’s opinion, impair the applicant’s ability to

perform the duties of a police officer or complete the required minimum training requirements? YES NO

Does the applicant have all extremities, including digits, required to meet minimum training requirements and perform police officer duties?

YES NO

THE APPLICANT SHOULD BE MARKED “CAPABLE” ON THE BACK OF THE FORM ONLY IF ALL QUESTIONS ABOVE ARE MARKED “YES”

DRUG SCREEENING: The applicant must be tested for and free from the presence of illegal controlled substances using a minimum of a five-panel

drug screen. The results of the drug screen must be attached to this form for review. Include a list of all medications currently taken by the applicant.

DATE TESTED TEST RESULTS ATTACHED YES NO

APPLICANT IS CURRENTLY TAKING MEDICATION YES NO MEDICATION LIST ATTACHED YES N/A

THE APPLICANT SHOULD BE MARKED “CAPABLE” ON THE BACK OF THE FORM ONLY IF THE RESULTS OF THE DRUG SCREEN ARE ATTACHED

HEARING: The applicant must be able to distinguish a normal whisper at 15 feet. The test shall be independently conducted for each ear, with the

tested ear facing away from the speaker and the other ear firmly covered with the palm of the hand. The applicant is prohibited from using a hearing aid

during the testing. If the applicant fails the whisper test, a decibel audio test is required with the following results: 25d b or better for pure tone stimulation

between 500Hz, 1000Hz, 2000Hz, and 3000Hz.

RIGHT EAR NORMAL LEFT EAR NORMAL

ABNORMAL ABNORMAL

THE APPLICANT SHOULD BE MARKED “CAPABLE” ON THE BACK OF THE FORM ONLY IF HEARING IS NORMAL IN BOTH EARS

VISION: The applicant must have vision of at least 20/70, uncorrected, in the stronger eye, correctable to 20/20; and at least 20/200, uncorrected, in the

weaker eye, correctable to at least 20/40; have normal depth perception and color vision, and must be free of any significant visual abnormality. If this

section is not completed during the physical, a separate vision exam must be completed using a Form MPO-211 (Vision Examination).

RIGHT EYE UNCORRECTED 20/ LEFT EYE UNCORRECTED 20/

CORRECTED 20/ CORRECTED 20/

Does the applicant have normal depth perception? (Stereopsis >48% or Arc Seconds <100)

YES

Does the applicant have normal color perception? (Farnsworth or Ishihara)

YES

Is the applicant free from any other significant visual abnormalities? YES NO

THE APPLICANT SHOULD BE MARKED “CAPABLE” ON THE BACK OF THE FORM ONLY IF VISION MEETS ALL STATED REQUIREMENTS

REMARKS

PROFESSIONAL OPINION

PHYSICALLY CAPABLE - I have examined the applicant, and it is my professional opinion that this person is physically capable of performing

the duties a certified police officer in Pennsylvania.

PHYSICALLY UNFIT - I have examined the applicant, and it is my professional opinion that this person is physically unfit of performing the

duties a certified police officer in Pennsylvania.

I hereby certify that the information and statements contained in the tables above and in the attached examination report are true and correct, and that I

am signing this document with the full understanding that any false information or statement will subject me to criminal penalties of Title 18, Crimes code,

Section 4904, relating to unsworn falsification to authorities.

This examination form must be forwarded to the employing police department, certified Act 120 police academy, or MPOETC by th e examining

physician within 15 days of the date of examination, even if the applicant is found physically unfit, pursuant to 37 Pa. Code § 21.11(4)(iv).

SIGNATURE – PENNSYLVANIA LICENSED EXAMINING PHYSICIAN/PA/CNP DATE

PHYSICIAN PRINTED NAME

LICENSE NO.

TELEPHONE NO.

STREET ADDRESS

CITY/BORO

STATE

ZIP CODE

RELEASE OF PHYSICAL INFORMATION

Having applied for certification/training as a police officer in Pennsylvania and having subjected myself to a physical examination by a

licensed physician, as required by the Act, I reserve the right to have the data and conclusions of the physician remain confidential except

to those whom I designate. Accordingly, I hereby authorize the physician named above to release all information relate d to my physical

examination to the Municipal Police Officer’s Education and Training Commission (MPOETC) AND to any additional police departments

and/or academies listed below, for purposes consistent with the application process pursuant to this Act. No other release of this

information, explicit or implied, is granted at this time.

MCCC Municipal Police Academy

NAME OF MUNICIPAL POLICE DEPARTMENT AND/OR CERTIFIED ACT 120 ACADEMY (Print)

340 DeKalb Pk HSC Blue Bell PA 19422 215 619 7176 jmckenna@mc3.edu

ADDRESS CITY STATE ZIP CODE FAX EMAIL

SIGNATURE – APPLICANT DATE

MPO-211 (3/2018)

MUNICIPAL POLICE OFFICERS’ EDUCATION AND TRAINING COMMISSION

8002 Bretz Drive

Harrisburg, Pennsylvania 17112-9748

http://www.psp.pa.gov/MPOETC

VISION EXAMINATION

This form is to be used by both municipal police officer applicants and police academy cadet applicants.

THIS EXAMINATION MUST BE ADMINISTERED by a licensed optometrist or ophthalmologist who is licensed in Pennsylvania. This examination is to

determine the physical fitness, specifically related to specific vision standards, of the applicant to be certified as a police officer in Pennsylvania. The

applicant who you are about to examine is applying for certification and will be vested with a position of public trust.

LAST NAME FIRST NAME MIDDLE INITIAL

STREET ADDRESS CITY/BORO STATE ZIP CODE

SOCIAL SECURITY NUMBER DATE OF BIRTH GENDER DATE OF EXAM

VISION: The applicant must have vision of at least 20/70, uncorrected, in the stronger eye, correctable to 20/20; and at least 20/200, uncorrected, in

the weaker eye, correctable to at least 20/40; have normal depth perception and color vision, and must be free of any significant visual abnormality.

RIGHT EYE UNCORRECTED 20/_____ LEFT EYE UNCORRECTED 20/_____

CORRECTED 20/_____ CORRECTED 20/_____

Does the applicant have normal depth perception? (Stereopsis >48% or Arc Seconds <100) YES NO

Does the applicant have normal color perception? (Farnsworth or Ishihara) YES NO

Is the applicant free from any other significant visual abnormalities? YES NO

THE APPLICANT SHOULD BE MARKED “CAPABLE” IN THE BLOCK BELOW ONLY IF VISION MEETS ALL STATED REQUIREMENTS

PROFESSIONAL OPINION

PHYSICALLY CAPABLE (VISION) - I have examined the applicant, and it is my professional opinion that the person named above meets the

vision standards which are described above and required to perform the duties a certified police officer in Pennsylvania.

PHYSICALLY UNFIT (VISION) - I have examined the applicant, and it is my professional opinion that the person named above does not meet

the vision standards which are described above and required to perform the duties a certified police officer in Pennsylvania.

I hereby certify that the information and statements contained in the tables above and in the attached examination report are true and correct, and

that I am signing this document with the full understanding that any false information or statement will subject me to criminal penalties of Title 18,

Crimes code, Section 4904, relating to unsworn falsification to authorities.

This examination form must be forwarded to the employing police department, certified Act 120 police academy, or MPOETC by the optometrist or

ophthalmologist within 15 days of the date of examination, even if the applicant is found physically unfit, pursuant to 37 Pa. Code § 21.11(4)(iv).

SIGNATURE – PENNSYLVANIA LICENSED OPTOMETRIST/OPHTHALMOLOGIST DATE

OPTOMETRIST/OPHTHALMOLOGIST NAME (PRINTED) LICENSE NO. TELEPHONE NO.

STREET ADDRESS CITY/BORO STATE ZIP CODE

RELEASE OF PHYSICAL INFORMATION

Having applied for certification/training as a police officer in Pennsylvania and having subjected myself to a vision examination by a licensed

optometrist or ophthalmologist, as required by the Act, I reserve the right to have the data and conclusions of the physician remain confidential except

to those whom I designate. Accordingly, I hereby authorize the optometrist or ophthalmologist named above to release all information related to my

vision examination to the Municipal Police Officer’s Education and Training Commission (MPOETC) AND to any additional police departments and/or

academies listed below, for purposes consistent with the application process pursuant to this Act. No other release of this information, explicit or

implied, is granted at this time.

____________________________________________________________________________

NAME OF MUNICIPAL POLICE DEPARTMENT AND/OR CERTIFIED ACT 120 ACADEMY (Print)

_______________________________________________________________________________________________________________________________________________________________

ADDRESS CITY STATE ZIP CODE FAX EMAIL

SIGNATURE – APPLICANT DATE

MCCC Municipal Police Academy

340 DeKalb Pike Blue Bell, PA 19422

215 619 7176 jmckenna@mc3.edu

MONTGOMERY COUNTY COMMUNITY COLLEGE

MUNICIPAL POLICE ACADEMY

Municipal Police Officers’ Basic Training Program (Act 120)

Physical Fitness Evaluation Individual Informed Consent Release

The fitness pre-test as well as the mandatory Municipal Police Officers’ Education and Training Commission

(MPOETC) Basic Physical Fitness Program, both test for:

Cardio-Respiratory Fitness

Muscular Strength and Endurance

Cardio-Respiratory Fitness is tested by evaluating the time required to run a distance of 1.5 miles and a 300

meter dash.

Muscular Strength and Endurance is determined by evaluating the number of sit-ups an applicant can

successfully complete in a prescribed time period and by using the bench press method.

Note: All MPOETC fitness testing procedures are age and gender adjusted, as per the Cooper Institute of

Aerobic Research.

Historically, the most physically demanding portion of the fitness test is the cardio-respiratory evaluation, the

purpose of which is to examine the participant’s heart rate response to exercise and recovery periods.

Occasionally, complications can occur during the mandatory fitness testing. If the applicant/cadet is not

tolerating the task well, i.e. experiencing shortness of breath, pains in the chest area, etc. it is the

applicant’s/cadet’s responsibility to cease all physical activity and notify the test monitor of his/her condition.

In signing this Consent and Release Form, you acknowledge that you completely understand the test and that

any questions you have are answered to your satisfaction. You also understand that every reasonable effort has

been taken to insure your health and safety, that you enter into the tests willingly, and that you hereby do

release and hold the Montgomery County Community College harmless from and against any and all loss, cost,

damage, injury to you, the participant, or damage to or loss of property during the course of such tests.

Furthermore, I agree to look to my physician for any medical care.

Signature of Participant Date

Print Name

MONTGOMERY COUNTY COMMUNITY COLLEGE

MUNICIPAL POLICE ACADEMY

DRIVER’S LICENSE INFORMATION

In consideration of my participation in the driver’s training course, I hereby give Montgomery

County Community College, Municipal Police Academy permission to investigate the status of my

license to operate a motor vehicle

Name as it appears on License

Date of Birth

Driver’s License Number

Issuing State

Date Issued

Expiration Date

Class of License

Address as it appears on License

Are you currently under suspension in ANY state? Yes

If yes, explain below

Have you ever had a license suspended or revoked? Yes No

If yes, explain below

Signature Date

MONTGOMERY COUNTY COMMUNITY

COLLEGE MUNICIPAL POLICE ACADEMY

MCCC POLICE ACADEMY REFUND POLICY

In the unlikely event that an academy class is cancelled, a full refund of your tuition will be

returned to you automatically.

If you withdraw from the Academy, a memorandum must be forwarded to the Director

explaining the reason for withdrawal. If you are requesting a tuition reimbursement, please refer

to MCCC Tuition Refund Policy.

The decision to attend the police academy is one to be reached prior to the first day of class, not after.

Do not assume that a transfer or refund will be approved.

As a matter of information, uniforms, and PT clothing and supplies are non-refundable.

Cadet Signature Date

MONTGOMERY COUNTY COMMUNITY

COLLEGE MUNICIPAL POLICE ACADEMY

FINANCIAL AID INFORMATION

MPT students can apply for the following financial aid programs:

Federal Pell Grants

Federal Stafford Loans (answer Yes to Question #27 on the FAFSA)

Alternative Loans

Montgomery County Community College Deferred Payment Loan Program

VA Benefits

To apply for the Federal Financial Aid Program, you must do so after your acceptance interview.

STEP 1 Complete the Free Application for Federal Student Aid (FAFSA) online

@ www.fafsa.ed.gov MCCC’s Federal Code is 004452.

STEP 2 Financial Aid Office at MCCC Central

MCCC

Financial Aid Office

340 DeKalb Pike Blue Bell, PA 19422

215 641-6566 Fax 215-619-7193

STEP 3 Complete the above steps at least 8 weeks prior to the start date of your program.

To apply for Alternative Loans visit www.estudentloans.com or www.teri.org to find lenders for

various loan programs.

MONTGOMERY COUNTY COMMUNITY COLLEGE

MUNICIPAL POLICE ACADEMY

Montgomery College Community College Deferred Payment Plan

Police Academy tuition is $ 5,995.00. There will be a $35 set up fee for this payment plan.

25% at registration – $ 1,535.00

25% before class starts - $ 1,500.00

25% one month of start date of class- $ 1,500.00

25% second month of start date of class -$ 1,495.00

Veterans Benefits

This course is approved by the State of Pennsylvania Approval Agency for payment of VA

Education Benefits. You may download an application to receive VA benefits at the following

website:

www.gibill.va.gov

For more info regarding your specific situation, you may contact: veterans@mc3.edu

Veterans Advisor

Montgomery County Community College

215 619-7307

ENTRANCE FITNESS TEST REQUIREMENTS

Entrance Exam (30% Cooper)

Male Standards by Age

Female Standards by Age

18-29

30-39

40-49

50-59

60+

18-29

30-39

40-49

50-59

60+

300 Meter Run (Time)

62.1

106.7

Bench Press (% body weight)

0.93

0.83

0.76

0.68

0.63

0.56

0.51

0.47

0.42

0.4

Sit Ups (1 Min Reps)

1.5 Mile Run (Time)

13:15

13:44

14:34

15:50

15:46

16:42

17:29

19:10

Testing Order:

300 Meter Run

Bench Press

Sit Ups

1.5 Mile Run

This is a cumulative test. Each event is pass/fail; thus, if one event is failed,

the entire test is failed. There is no "averaging" of scores. Applicants for

the police academy will need to pass each event at the 30th percentile to be

considered for acceptance into the police academy. These scores are based

on The Cooper Institute data. If an applicant does not fall into one of the

age categories, the applicant will be required to receive a score closest to

their actual age.

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