City of Topeka | Citizens Academy Application

Fill out and submit this form - or download a printable version here.

Personal Data

Last Name

First Name

Full Middle

List all other names you have used, including nicknames and maiden names

If you have ever used any other surnames, or legally changed your name, please state
the time period this occurred and the circumstances. If you have ever legally changed
your name, please list date, place, and court:

Date of birth Place of birth Age

Drivers License Number Race

Social Security Number

Gender

Address and Point of Contact

Address

City St Zip Code

Home Phone Work Phone

Cellular phone E-mail address

Please list (below) the name and phone number of a relative or close associate (to be used in the event of an emergency):

Name Phone Number

Employment Information

Current Employer

Address

City St Zip Code

Job Title

Length of time with current employer

If less than three years please list former employer

Authorization to Conduct Law Enforcement Checks

Have you ever been charged with a felony offense?

Have you ever been convicted of a crime?

If yes, list details (below) pertaining to conviction, including date, place, law enforcement agency, charge, court and disposition

I hereby authorize the Topeka Police Department to conduct a criminal history check of law enforcement records as they pertain to me, I understand that this check will include, but not be limited to, any record of charges, prosecutions, or convictions for criminal or civil offenses. This check will be used for the purpose of the Topeka Police Citizens Academy application process. My consent is valid for six months from the date authorized below. Any information obtained will be used for the purpose of providing clearance to participate in the Topeka Citizens’ Academy.

Full Name Date of Authorization

Notice: Applicants must live, work, or have an interest in the City limits of Topeka, KS and must be at least 18 years of age. A criminal back ground check will be made on applicants before they are accepted to the academy. Applicants can not have a felony conviction and cannot have a DUI or drug conviction in the last seven (7) years.

Organization Memberships

Please list (below) any organizations or community groups to which you belong

How did you hear about Citizen’s Academy?

Medical

Do you now, or have you ever had a serious illness, or chronic illness, or injury that could preclude

If yes, provide details (below)

For more information call Crime Prevention Unit (785) 368-9497 or email Sgt. Lance Feyh at lfeyh@topeka.org