| Select Class Preference |
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| Application Date |
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| Agency |
| Name of Agency |
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| Address of Agency |
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| Agency Contact (Last Name, First Name) |
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| Agency Contact Phone Number |
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| Agency Contact Fax Number |
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| Agency Contact Email Address |
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| Date of Hire |
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Applicant's Name (As it appears on your driver's license)
(Last Name, First, Middle)
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Title/Rank |
Gender |
Date of Birth |
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Applicant's Address |
City |
State |
Zip |
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| Applicant's Email Address |
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| Social Security Number |
Drivers License Number |
State |
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| Applicant's Home Phone |
Applicant's Cell Phone |
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Age |
Shirt Size |
Height |
Weight |
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ight |
| Weapon |
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| Briefly describe your law enforcement experience. |
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| Do you have any physical limitations, injuries, or conditions which prevent
unrestricted, regular participation in FIREARMS TRAINING OR DEFENSIVE TACTICS?
(Including takedowns, handcuffing procedures, impact weapon use, running, etc) |
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| If you answered yes, please provide specific details: (If no, please type
"n/a".) |
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| I certify that I will abide by the rules and regulations of my agency and C.
A. R. T. A. (Capital Area Regional Training Academy).
I certify that the foregoing answers are true and correct to the best of my
knowledge and belief. I further certify that I am a full time commissioned Law
Enforcement Officer, or will be upon completion of this academy. I have also
read and understand the included documents.
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