Citizen's Academy Application - Linn County Sheriff's Office

Company

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

Identification

Name*

First Middle Last

Date of Birth*

Social Security Number (SSN)*

Driver's License Number*

State of Issue*

Contact Information

Home Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

Email Address*

Primary Phone*

Please list your cell phone number, if you have one, so we may contact you if there are cancellations or other necessary information we need to deliver to you in a timely manner. Thank you.

Other Names Used

Emergency Contact

Name*

First Last

Phone*

Alternate Phone

Personal References

First Reference

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Second Reference

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Information

Current Occupation

Have you ever been arrested for any criminal offense?*

no
yes

Please explain the circumstances of your arrest:

Citizen's Academy

How did you hear about the LCSO Citizen’s Academy?

What do you expect to gain by attending?

Permission to Conduct Background Check

Background Check Authorization*

I hereby authorize the Linn County Sheriff's Office, the Law Enforcement Data System (LEDS) and the Department of Motor Vehicles (DMV), and their agents to access my criminal history and motor vehicle records, including, but not limited to arrests, warrants, convictions, and disposition of charges.

I understand that these matters are confidential and I give my full release and agreement to the Linn County Sheriff's Office to use LEDS and DMV information to determine my eligibility for acceptance into the Citizen Academy.

The Linn County Sheriff's Office shall make all reasonable efforts to keep this information confidential. However, I release the Linn County Sheriff's Office, LEDS and DMV from liability concerning the release of information.

I certify that I have read, and authorize the Linn County Sheriff's Office to conduct a background check, to determine my eligibility to participate in the Citizen Academy. Further, I intend my electronic signature below to denote my agreement to this section, and to be the legally binding equivalent of my traditional handwritten signature.

Release, Indemnification, and Hold Harmless Agreement

Please read, review, and e-sign.*

I, in consideration for the privilege of participation in the Linn County Sheriff's Office Citizen Academy recognize such activity involves inherent risks and dangers. I do hereby agree to assume all risks associated with participation in the Citizen Academy hosted and conducted by the Linn County Sheriff's Office.

I have reviewed the job description and meet the minimum requirements to participate in the Citizen Academy.

I will defend, indemnify and hold harmless Linn County, and the Linn County Sheriff's Office, its officers, employees, and agents from and against all liability or loss and against any and all claims, actions, causes of actions, proceedings or appeals based upon or arising out of or arising from or in connection with my conduct, actions or performance as a participant in the Citizen Academy with the Linn County Sheriff's Office, including but not limited to damage or injury to persons or property including without limitation attorney fees and expenses; except for losses, claims or actions resulting from the sole negligence of Linn County, and the Linn County Sheriff's Office.

I certify that I have read, and agree, to the Release, Indemnification, and Hold Harmless Agreement above. Further, I intend my electronic signature below to denote my agreement to this section, and to be the legally binding equivalent of my traditional handwritten signature.

Signature and Certification

Certification*

I have read the entire text of this application and understand it completely. The statements I have made are correct and true. I understand that making false statements on this application is a crime. If I have made false statements in this application, I am subject to prosecution and my application will automatically be denied or revoked.

I certify that I intend my electronic signature on this application to be the legally binding equivalent of my traditional handwritten signature.

Signature*

Enter your full legal name.

Date Signed*

Citizen’s Academy Application