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  1. Town Logo - PD - Black
  2. Prescott Valley Police Department Internship
  3. Month/Day/Year
  4. If yes please explain, if no simply type No.
  5. Yes or No
  6. If yes, please list all names used and the reason for each (include the dates alias was used). If no, simply type no.
  7. Yes or No
  8. Yes or No
  9. Yes or No
  10. Name, Address, Phone Number, Years Known, and Email
  11. Yes or No
  12. If yes please explain
  13. If yes, please list the date, type of violation, and location/issuing agency
  14. If yes, approximately how many times
  15. If yes, please explain
  16. If yes, how many times. How many times after age 21. Date first used and date late used.
  17. If yes, how many time. How many times after age 21. Date first used and date late used.
  18. Include, if applicable, the following: How the drug was ingested or consumer, the duration of usage, the motivation for use, how the drug was obtained, why you stopped using the drug, and if there are any other factors you believe are relevant.
  19. Waiver & Liability Release Form

    Please email or visit the station in person to pick-up the Waiver & Liability Release Form.

  20. I hereby certify under penalty of law that the entries on this statement and the attached continuation page are true, complete and correct to the best of my knowledge and belief. These entries are made in good faith. I understand that a false or misleading statement on this form constitutes a violation of the law and is cause to deny my application.
  21. I understand, for security reasons, a criminal history check will be conducted, and I will be fingerprinted. Further background information may be requested if a specific volunteer assignment calls for a full-security check which could include a polygraph examination.
  22. I further understand and agree that any illegal activity in which I have been involved that is discovered during this background/criminal history investigation will be disclosed to the proper authorities if applicable.
  23. First and Last Name
  24. Month/Day/Year
  25. Leave This Blank:

  26. This field is not part of the form submission.