Citizens' Police Academy - City of Nixa, MO

This field is for validation purposes and should be left unchanged.

Date of Application(Required)

Name(Required)

First Last

Date of Birth(Required)

Untitled

White

African American/Black

Hispanic/Latino

American Indian/Alaskan Native

Asian

Other

Gender

Male

Female

Other

Driver's License Number(Required)

Full Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone

What type of phone is that?

Cell

Home

Work

Are Your Employed?

Yes

Employer Name(Required)

Employer Phone(Required)

Employer Full Address(Required)

Street Address Address Line 2 City State ZIP Code

Have You Ever Been Arrested for a Felony or Misdemeanor?

Yes

Please provide the details of the arrest

Include the date, place of arrest, and disposition

*Can you commit to attending the required classes for the duration of the Academy?(Required)

Yes

Note: To graduate from the Academy, you can not miss more than 3 classes

Have you ever had anycontact with the Nixa Police Department?(Required)

Yes

If so, in what capacity?(Required)

Why do you want to participate in the Nixa Citizens' Police Academy?(Required)

Have you ever previously applied for the Nixa Citizens' Police Academy?(Required)

Yes

When had you applied?

How did you hear about Nixa's Police Academy?(Required)

Shirt Size(Required)

Unisex T-shirt

Please Review Your Answers and Read the Following Statement Before Signing This Application

I hearby affirm, by signing my name below and submitting this electronically, that there are no willful misrepresentations, omissions, or falsifications in the foregoing statementsand answers to questions. I understand that any omission or false statements on thisapplication shall be sufficient cause for rejection for enrollment or dismissal from the Nixa Citizen’s Police Academy. I further understand the Nixa Police Department will be conducting a thorough background investigation that may include, but not limited to a criminal history check. I declare that I have never been convicted of a felony offense. I also understand that any student may be removed from the Nixa Citizens’ Police Academy if said student is disruptive or otherwise inhibits the concept of the program. I will also abide by all the rules and regulations set forth by the Nixa Police Department and the City of Nixa.

Electronic Signature

Please enter your name below for the purpose of electronically signing this report (RSMO 432.200 / E-Sign Act)

Citizens’ Police Academy

Nixa Youth Citizens’ Police Academy Application

Please Review Your Answers and Read the Following Statement Before Signing This Application

Police Department

Department Contact

Contact Person

Dennis Acox