STUDENT'S POLICE ACADEMY APPLICATION

Please print and complete the form as fully as possible.  When completed, sign and date the form and drop it off at the Virginia Tech Police Department or mail it to Officer Geof Allen, Sterrett Facilities Complex, Blacksburg VA 24060

Name (Last, First,Middle):_________________________________________________

SSN:  ______________________                    Sex: ________

Address:________________________________________________________________

Telephone:  _____________________________          Email: ______________________

Birth Date:  ____________   Place of Birth (City and State):_______________________

Do you have any physical disabilities for which the police department may have to make accommodations?  _______  If so, please detail the disability and tell us what accommodations:  ________________________________________________________________________________________________________________________________________________________________________________________________________________________

 Have you ever been arrested for anything other than traffic violations?  ______  If so, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Why do you wish to participate in this program?  ________________________________________________________________________________________________________________________________________________________________________________________________________________________

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As a requirement for the Student's Police Academy, the Virginia Tech Police Department performs a criminal history check on all applicants that are initially selected to participate in the program.  All records are confidential and will be shredded upon termination of their use for this purpose.

 I hereby authorize the Virginia Tech Police Department to search the files of the Central Criminal Records Exchange for any criminal history record.

Applicant's Signature                                        Date

______________________                            ________________