Portage Police Department
Citizens Police Academy Application
Contact information and Background Screening
The Portage Police Department is proud to host its’ annual Citizens Police Academy. This 10
week course is free-of-charge to participants who have a connection to Portage and pass a
background check. This course will be on Tuesday nights starting in January and ending in
March. The start date will be given out to accepted applicants.
Thank-You for your interest in law enforcement and taking time out of your busy life to join us,
the Portage Police Department, for an experience that I hope answers questions and offers
insight. With that said, we ask that you attend at least 8 out of the 10 sessions.
Participant Information:
NAME:_______________________________________(First, MI, Last)
DOB:____/_____/______ Driver’s License #______________________
ADDRESS:__________________________________________________________
PHONE #:_______________________________
EMAIL ADDRESS:______________________________________
OCCUPATION:________________________________________
What do you hope to gain with your attendance in the Citizens Academy?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Where did you hear about our Academy?
______________________________________________________________________________
______________________________________________________________________________
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.
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