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2. First Name*
3. Last Name*
4. Date of Birth*
   Please use this format: 00/00/0000
6. Address*
7. Phone Number*
9. Business Name & Address
   *Complete only if Malden business owner
11. Email Address*
12. Occupation*
14. Driver's License or Social Security Number*
15. Are you okay with being photographed for social media?*
    -- Select One --YesNo
17. Please briefly explain why you would like to participate in the Citizen's Police Academy and what you hope to gain from the experience*
19. I hereby certify that all statements made by me are, to the best of my knowledge, true and accurate. I hereby authorize the Malden Police Department to conduct whatever records checks are necessary to determine my status as a criminal offender including a search of the records of the Department of Criminal Justice Information Services.
21. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
23. Electronic Signature
Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field