OFFICE USE ONLY
Please Return To: Date Received:
B
ackground Check:
Notified:
Murray Police Dept.
Crime Prevention Division
104 N. 5th Street
Murray, KY 42071
Last Name:__________________________ First Name:_________________ Middle Name:_______________
Street Address:_____________________________________________________________________________
City:________________________________ State:_____________________ Zip:_______________________
How long have you lived at your present address? Years:____________ Months:___________________
Previous Address:___________________________________________________________________________
(If less than 5 years at present address)
Sex: M F Driver's License #_______________________________________
Circle One State Number
Email Address:_____________________________________________________________________________
Date of Birth:_________________________________ Phone:______________________________________
Employer Name:_______________________________ Occupation:__________________________________
Employer Address:__________________________________________________________________________
Employer Phone:___________________________________________________________________
List three personal references (Name, Address, Phone)
Applicants must also be no less than 21 years of age.
I,
the undersigned understand that a background check will also be conducted on me. I also understand
and agree to the fact the Murray Police Department reserves the right to deny entry into the Citizens
Police Academy based on the finding of the background check and/or any other lawful reason and is not
required to disclose that reason to me. I understand that class size is limited and that I may be denied or
offered a later class for this reason alone.
Applicant Signature:______________________________________________
Murray Police Department
Citizens Police Academy
Application Form
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signature
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