Fill - Free fillable Form 2022: CITIZENS POLICE ACADEMY APPLICATION PDF form

This PDF contains form elds which allow you to ll

in your name and information before printing this

document from your computer. After the forms are

lled out online, print out all pages of this PDF.

Sign and date all of the document pages EXCEPT for

page . Only ll out the top part of page – DO

NOT sign or date this page.

After all pages have been properly lled out

and signed:

Once your application is processed, you’ll be

scheduled for a short interview. Please bring

your photo ID with you for the interview.

Scan & email all documents to:

gantinozzi@chambleega.gov

(Bring all original signed documents with you to

the rst day of class.)

–OR –

Mail the originals to:

Attn: Chamblee Police Auxiliary

Citizens Police Academ

c/o Chamblee Police Department

4445 Buford Highway

Chamblee, GA 30341

INSTRUCTIONS

4 4

CITIZENS POLICE ACADEMY APPLICATION

2022

Be 18 years of age by the rst day of class

Participants must live or work in Chamblee

Be able to provide a government-issued photo

identication card

Submit to a limited background

investigation including:

Criminal history

Driving history

e approved by Lt. Guy Antinozzi after successfully

completing the background investigation

REQUIREMENTS

CONTACT

For questions or mor

e information,

contact Lt. Guy Antinozzi at

470-395-2447 or

gantinozzi@chambleega.gov.

I, ____________________________________, hereby authorize the Chamblee Police Department to

obtain and/or receive any Criminal History record and/or Driver History record information pertaining

to me, which may be in the les of any state or local criminal justice agency in Georgia, any other State

or any other country.

A photocopy of this release form will be valid and considered as an original hereof, even though the

said photocopy does not contain an original signature.

This release is executed with full knowledge and understanding that the information is for the ocial

use of the Chamblee Police Department to furnish such information, as is described above, to third

parties in the course of fullling its ocial responsibilities.

I hereby waive and release any claims against any party which I may have as the result of the release

of any records or information referenced in this Authorization and acknowledge that no party shall

have any liability to me as a result of complying with a request for such information and/or records.

I am furnishing my Social Security number on a voluntary basis with the understanding that such is

not required by federal statute or regulation. I have been advised that this number will be utilized

only to facilitate the location of above information and/or records concerning me in connection with

this application. Should there be any questions as to the validity of this release, you are permitted to

contact me as indicated below.

CITIZENS POLICE ACADEMY APPLICATION

_____________________________________________ _______________________

(SIGNATURE OF APPLICANT) (DATE SIGNED)

City of Chamblee Police Department

3518 Broad St. | Chamblee, GA 30341 | 770-986-5005 | chambleega.gov

In consideration for being allowed to participate in the City of Chamblee Police Department Citizens

Police Academy program, which will provide me an opportunity to gain supervised experience in

the Police Department, I, ____________________________________, release the City of Chamblee,

the Chamblee Police Department, and the ocials, ocers and employees of the City of Chamblee

and the Chamblee Police Department from liability for any harm, injury, or damage which I may

suer while I am participating in this program. This includes all risks that relate to this work, whether

foreseen or unforeseen, including riding as a passenger in an ocial Chamblee Police Department

vehicle. This release applies to damages suered by me, as well as my family, heirs, and assigns as a

result of any harm or injury I may suer.

I, ____________________________________, agree to hold the City of Chamblee, the Chamblee

Police Department, and its ocials, agents, and employees harmless from any claim(s) by me, my

family, my estate, my heirs or assigns, arising out of my participation in this program.

I, ____________________________________, agree that I will hold harmless, indemnify and defend

the City, its agents and employees from any damage to persons or property resulting from my

negligence and/or intentional acts.

I, ____________________________________, assume the responsibilities of physical tness and

ability to participate in this program, and agree to abide by all rules and requirements of the program.

I have read the contents of this release. I understood the terms and conditions and signed this release

of my own free will.

CITIZENS POLICE ACADEMY APPLICATION

_____________________________________________ _______________________

_______________________

(SIGNATURE OF APPLICANT) (DATE SIGNED)

(SIGNATURE OF NOTARY PUBLIC) (DATE SIGNED)

(MY COMMISSION EXPIRES) (STAMP/SEAL)

City of Chamblee Police Department

3518 Broad St. | Chamblee, GA 30341 | 770-986-5005 | chambleega.gov

RELEASE AND HOLD HARMLESS AGREEMENT

A person who lives or works in the City of Chamblee, who makes an application to the Citizens

Police Academy, and is accepted as a participant will, at all times, be courteous to other participants

and City of Chamblee sta members. Alcohol and tobacco usage (including vaping) while in class or

within the City of Chamblee Police Department is strictly prohibited. Participants must be 18 years

of age or older by the rst day of class.

CITIZENS POLICE ACADEMY APPLICATION

I, ____________________________________, make application to the City of Chamblee Police

Department to participate as a student in the Citizens Police Academy. I understand that I will be

required to successfully complete a background investigation and, if accepted as a student, attend

the class orientation and subsequent sessions. I understand that I will be held to the highest standards

of professionalism at all times.

_____________________________________________ _______________________

(SIGNATURE OF APPLICANT) (DATE SIGNED)

(RECEIVED BY - EMPLOYEE) (DATE RECEIVED)

BACKGROUND COMPLETED (SEE SOP C-5):

BACKGROUND CHECK COMPLETED BY:

DOES APPLICANT HAVE A CRIMINAL HISTORY?

ONLY

DEPT USE

_______________________________ _______________________________ __________

______________________________________________________________________________

___________________________________________________

________________________ ________________________ ________________________

(LAST NAME) (FIRST NAME) (M.I.)

(ADDRESS)

(CITY) (STATE) (ZIP CODE)

(DATE OF BIRTH) (PRIMARY TELEPHONE) (ALTERNATE TELEPHONE)

(EMAIL ADDRESS)

________________________ ________________________ ________________________

________________________

(HOW MANY YEARS

IN CHAMBLEE?)

City of Chamblee Police Department

3518 Broad St. | Chamblee, GA 30341 | 770-986-5005 | chambleega.gov

I hereby authorize a Chamblee Police Department Certied Agent to receive any Georgia criminal

history record information pertaining to me which may be in the les of any state or local criminal

justice agency in Georgia.

CITIZENS POLICE ACADEMY APPLICATION

** THIS AUTHORIZATION IS VALID FOR THIRTY (30) DAYS FROM DATE OF SIGNATURE **

Purpose of Request:

______________________________________________________________________________

________________________ ________________________ ________________________

(FULL NAME - print)

(ADDRESS)

(CITY) (STATE) (ZIP CODE)

(SEX) (RACE) (DATE OF BIRTH) (SOCIAL SECURITY NUMBER)

___________ ___________ ________________________ ________________________

___________________________________________________

(SIGNATURE) (DATE)

________________________

___________________________________________________

(CHAMBLEE POLICE DEPARTMENT CERTIFIED AGENT) (DATE)

________________________

Personal Inspection (U)

Employment- General (E)

Adoptions (E)

Employment with mentally disabled (M)

Employment with elder care (N)

Employment with children (W)

Ride-Along Program (C)

Explorers Program (C)

Volunteer Police Ocers (J)

Public Records- Felony convictions (P)

Requestor’s Name: _____________________________________

Other: Applicant for Citizens Police Academy

________________________________________________

CRIMINAL HISTORY RECORD CHECK CONSENT FORM

City of Chamblee Police Department

3518 Broad St. | Chamblee, GA 30341 | 770-986-5005 | chambleega.gov

CITIZENS POLICE ACADEMY APPLICATION

I, ____________________________________,

submit this application to the City of Chamblee

Police Department to participate as a student in the Citizens Police Academy. I understand

that I will be required to successfully complete a background investigation and, if accepted

as a student, attend the class orientation and subsequent sessions. I understand that I will

be held to the highest standards of professionalism at all times.

_____________________________________________ _______________________

(SIGNATURE OF APPLICANT) (DATE SIGNED)

(RECEIVED BY - EMPLOYEE) (DATE RECEIVED)

BACKGROUND COMPLETED (SEE SOP C-5):

BACKGROUND CHECK COMPLETED BY:

DOES APPLICANT HAVE A CRIMINAL HISTORY?

ONLY

DEPT USE

person who lives or works in the City of Chamblee, who submits an application for the

Citizens Police Academy, and is accepted as a participant will, at all times, be courteous to

other participants and City of Chamblee staff members. Alcohol and tobacco usage (including

vaping) while in class or within the City of Chamblee Police Department is strictly prohibited.

Participants must be 18 years of age or older by the first day of class.

_______________________________ _______________________________ __________

______________________________________________________________________________

___________________________________________________

________________________ ________________________ ________________________

(LAST NAME) (FIRST NAME) (M.I.)

(ADDRESS)

(CITY) (STATE) (ZIP CODE)

(DATE OF BIRTH) (PRIMARY TELEPHONE) (ALTERNATE TELEPHONE)

(EMAIL ADDRESS)

________________________ ________________________ ________________________

________________________

(

HOW MANY YEARS HAVE YOU

LIVED/WORKED IN CHAMBLEE?)

City of Chamblee Police Department

4445 Buford Highway | Chamblee, GA 30341 | 770-986-5005 | chambleega.gov