Background Information:
Have you ever been arrested or convicted of a crime?
If yes please provide details:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you been found guilty of a felony? YES or NO
Do you have any special accommodations that the Portage Police Department needs to know
about? If yes, please list below.
______________________________________________________________________________
______________________________________________________________________________
Authorization and Release
I understand that due to my participation in the Citizens Police Academy the Portage Police
Department will conduct a criminal background check and driving history check to ensure the
safety of all involved. By signing below, this authorizes the release of my information to Portage
Police Department solely for the purpose of entry into the CPA Program and that all of the
information on this application is true to the best of my knowledge.
Furthermore, I hereby release the Portage Police Department, its officers or representatives,
and any entity providing information pursuant to this authorization and release of information,
from all liability upon the provision of that information.
The Portage Police Department does have the right to deny participation based on the
background check.
Signed:___________________________ Date:______________
Please return this application to Portage Police Department Attn: Lt. Keith Klafke. Information
on this form will be kept secure by Lt. Keith Klafke at the Portage Police Department.
