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Basic Peace Officer Training Academy Enrollment

Upon submittal of this form, you will be contacted by the Academy Commander.

 
Personal Information
First Name
Last Name
Middle Name
Maiden Name
Street Address
City
State
Zip Code
County
Telephone
E-Mail
Date of Birth
 
Male Female
Weight lbs.
Ohio Driver's License No. Exp. Date
Your driver's license is: Valid Suspended
Are you insured to operate a motor vehicle? Yes No
If no, you will be required to show proof of coverage prior to participating in driving.
Which police academy will you be attending? Day Evening
 
Place of Birth
City
County
State or Country
 
Education Background
High School Associate Degree Bachelor's Degree
Master's Degree Other Type
 
Agency Information
   
If you are being sponsored by an agency (not open enrollment), please provide the following information:
Appointing Agency
Address
City
State
Zip Code
County
Date of Appointment
Position/Title
 
By submitting this form, I certify that the above statements are true to the best of my knowledge. I will abide by the rules and regulations of Clark State Community College.
 

Admissions Office
Sara T. Landess Technology and Learning Center
937/328-6028
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Greene Center
937/429-8819
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