2. First Name*
3. Middle Name*
4. Last Name*
6. Address*
8. City*
9. State*
10. Zip*
12. Email*
14. Telephone:*
15. Work/Other:*
16. Cell:*
18. Date of Birth:*
    Date of Birth:
19. Age:*
20. Social Security Number:*
21. Driver's License Number/State:*
23. Educational Background:
25. High School:
26. Diploma or GED:
    -- Select One --GEDDIPLOMA
28. College Name:
29. Degree Received:
31. Occupation:
32. Employer:
34. Organizations you are a member of (Civic, Community Clubs, Neighborhood Watch, etc.):
36. Why do you wish to attend the St. Charles Parish Sheriff's Office Citizens Academy?*
38. Have you ever been convicted of a crime?*
    -- Select One --YesNo
39. If YES, explain:
41. I give my permission to the St. Charles Parish Sheriff's Office to conduct a criminal history background check to determine my acceptance into the Citizens Academy.*
    -- Select One --YESNO
43. I DO HEREBY AUTHORIZE any and all persons, employers, Partnerships, corporations, and all civilian and government entities, military agencies, law enforcement agencies, private, City, County, State and Federal entities to release, furnish and exchange any and all available information relating to me for the purpose of determining my suitability to be appointed as a member of the St. Charles Parish Sheriff’s Office Citizens Academy. This includes, but is not limited to, all information related to my character, integrity, reputation, conduct and behavior. This authorizes release to the St. Charles Parish Sheriff’s Office. This release is in addition to, and intended to curtail or diminish, the authorization and immunity provided by statute. I DO HEREBY RELEASE from any and all liability, all persons or entities disclosing information pursuant to this release.By typing my full name (first, middle, last) in the box, I agree to the above statement for the authorization to release my information.*

    Please type your full name above (first, middle, and last).

Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit Submit and Print

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