2. La Vista Police Department Community Police Alliance Application
4. Name*
5. Date of Birth*
7. Street Address*
9. City, State, Zip*
11. Home Phone*
12. Alternate Phone
14. Email Address*
16. Driver's License Number
17. State
19. Occupation*
21. 
    
23. Briefly explain why you want to participate in this program.*
25. PLEASE NOTE:
27. A criminal history check will be conducted on each applicant prior to their approval for admittance into the Citizen’s Police Academy.
    
    Some of the course content may be graphic in nature and some the terminology may be offensive. Please be aware of this prior to applying for the program, and please be aware that you may be excused from the class if the need arises.
    
    Class size is limited; you will be notified of your application status.
    
    Applicants must be at least 17 years of age.
    
29. BY TYPING IN MY SIGNATURE BELOW AND CLICKING SUBMIT, I AGREE TO THE TERMS AND CONDITIONS OF THIS APPLICATION.
31. 
    
33. Signature*
35. Date Application was Submitted*
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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field