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3. 
6. Citizens on Patrol Application
   If a field is marked *, it is required. If a field is not applicable, please type N/A in the field.
8. Name*
10. Please list any other names used.
12. Phone Number*
13. Date of Birth*
    Date of Birth
15. Street Address*
17. City*
18. State*
19. Zip*
21. Email Address*
23. Are you presently employed?*

    1. Yes

    1. No
24. Full-Time or Part-Time?

    1. Full-Time

    1. Part-Time
26. Please list the name and address of your employer.
28. Have you ever been arrested?*

    1. Yes

    1. No
30. If yes, please explain.
32. Have you ever been convicted of any offense other than minor traffic citations?*

    1. Yes

    1. No
34. If yes, please explain.
36. Have you ever been the victim of a crime?*

    1. Yes

    1. No
38. If yes, please explain.
40. Was this crime reported to the police?

    1. Yes

    1. No
42. 1. Reference Name*
44. Reference Address*
46. City*
47. State*
48. Zip*
50. 2. Reference Name*
52. Address*
54. City*
55. State*
56. Zip*
58. How often are you available at work?*
60. In case of an emergency, please contact:
62. Name*
64. Address*
66. City*
67. State*
68. Zip*
70. Agreement
    I hereby certify by my signature that the information contained herein is truthful and there are no willful misrepresentations or falsifications in this application, and all answers are true and correct to the best of my knowledge.
    
    I hereby authorize the City of Sterling Heights to make a thorough investigation of my past employment, driving record, criminal conviction records, and educational attainment. I agree to cooperate in such investigation and I release the City and any person or organization supplying information to the City in connection with such investigation of and from liability in connection with the furnishing or use of such information.
72. Full Name*
73. Date*
    Date
Leave This Blank:


75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

* indicates a required field