SIGN UP FORM for 2012 Classes

Please fill out the form below with correct and accurate information. Applications for the next class are on a first come first serve basis. IMPORTANT: Please fill in all fields marked with a *.  By submitting this application, you understand and agree that a background investigation will be conducted on you. Any criminal convictions, any previous actions which could reflect unfavorably on the Miami Beach Police Department, any suggestion that I might be a security risk, or any attempt to deceive or conceal pertinent information, will be cause for denial of this application.

Today's Date*
Email Address*
First Name* No Nicknames
Middle Name
Last Name*
Date Of Birth*
Sex*	Female Male
Race*	White Black Other
Address* No P.O. Boxes
City*
State*
Zip*
Home Phone*
Cell or Alternate Phone*
Place of Employment and Address*
Job Title*
Are you a Criminal Justice Student*	Yes No
If Yes. What School
Have You Ever Been Arrested*	Yes No If yes, you must fax the following information to Lori at 786-394-4980 in order to be considered as a student: Copy of arrest form showing clearly the arresting agency, their case number and the charges, a copy of court documents showing the outcome of the charges, and a statement in your own words of what transpired.
If Yes, Please explain the circumstance
Any Physical Limitations
Why I want to attend*
Emergency Contact*

By submitting this information to the Miami Beach Citizens' Police Academy and the Miami Beach Police Department, you swear that the above information is true. You understand and agree that a thorough background check will be done and that you will be contacted by a representative of the Miami Beach Citizens' Police Academy to inform you of your enrollment status. You understand that by sending this form you are NOT guaranteed a spot in any of the classes. By becoming a student, it is understood that your photo or likeness might be posted on the internet or in advertisements for the program at the discretion of the Police Department or CPA Alumni Association. If you have any questions or problems with regards to the program, please contact the class coordinator.

THIS IS NOT AN APPLICATION TO BE A POLICE OFFICER.