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2. 
5. Prescott Valley Police Department Internship
7. Education Institution
9. First Name
10. Last Name
12. Address1
14. City
15. State
16. Zip
18. Home Phone Number
20. Cell Phone Number
22. Work Phone Number
24. Email Address
26. Date of Birth
    Month/Day/Year
28. Social Security Number
30. AZ Driver's License Number
32. Driver's License Expires
34. Has your license ever been suspended or revoked
    If yes please explain, if no simply type No.
36. Do you currently have automobile insurance
    Yes or No
38. Name of auto insurance company
40. Have you ever used any other names
    If yes, please list all names used and the reason for each (include the dates alias was used). If no, simply type no.
42. High School Attended and Address
44. High School Diploma/GED Received
    Yes or No
46. College Attended and Address
48. Course of Study
50. Degree Received
    Yes or No
52. Employer (Most Current)
54. Position held
56. Employer Address and Phone Number
58. Please list any special skills, training or interests you have that may be useful in your duties as a police intern
60. Do you have previous experience in Law Enforcement
    Yes or No
62. If yes, please list the name and location of the organization(s)
64. Please provide us with the contact information for three references
    Name, Address, Phone Number, Years Known, and Email
66. Have you ever been arrested
    Yes or No
68. If yes, please explain (include date, location, and circumstances)
70. Have you ever been convicted of a crime
    If yes please explain
72. During the last five years, have you received a traffic citation
    If yes, please list the date, type of violation, and location/issuing agency
74. During the last five years, have you driven a motor vehicle while intoxicated
    If yes, approximately how many times
76. Have you ever been a member or associated with any organization that advocates violence, terrorism or anti-government
    If yes, please explain
78. In a few words, what interested you in participating in the internship program at the Prescott Valley Police Department
80. Have you ever sold, smuggled, or transported for sale of personal use the following drugs: Marijuana (non-medical), Cocaine/crack, Methamphetamine/Speed, Heroin, Opium, Morphine, LSD/Acid, Peyote, Mescaline, Hashish, Steroids, Any other illegal drug or narcotics, Illegal use of prescription drugs
    If yes, how many times. How many times after age 21. Date first used and date late used.
82. Have you ever used, tried, or experimented with the following drugs: Marijuana (non-medical), Cocaine/crack, Methamphetamine/Speed, Heroin, Opium, Morphine, LSD/Acid, Peyote, Mescaline, Hashish, Steroids, Any other illegal drug or narcotics, Illegal use of prescription drugs
    If yes, how many time. How many times after age 21. Date first used and date late used.
84. If you answered yes on any of the above questions please provide a full explanation below.
    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.
86. Waiver & Liability Release Form

    Please email pdcpo@prescottvalley-az.gov or visit the station in person to pick-up the Waiver & Liability Release Form.

88. 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.
90. 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.
92. 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.
94. Signature
    First and Last Name
96. Date
    Month/Day/Year
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100. 1. Receive an email copy of this form.
101. Email address

     This field is not part of the form submission.

102. Submit Submit and Print

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