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2. Name*

   Enter first and last name.

3. Date of Birth*

   Use format : xx/xx/xxxx

5. Street address*
7. City*
8. State*
9. Zip*
11. Home Phone*

    use format : ###-###-####

12. Cell Phone*
14. Employer*
16. Email Address*
18. How long have you lived in Lawrenceburg/Lawrence County?*
20. Gender*

    1. Male
    2. Femail
    3. Prefer not to answer
21. Shirt Size*
23. Why do you want to attend The Citizen's Fire Academy?*
25. How did you hear about The Citizen's Fire Academy?*
27. Have you ever been convicted of a felony?

    1. yes
    2. no
28. Have you ever been convicted of a felony involving moral turpitude? *

    1. yes
    2. no
30. Do you have any severe physical limitations which would hinder you from engaging in activities associated with the Citizen’s Fire Academy? *

    1. yes
    2. no
31. I am willing to undergo a minimum background investigation by the Lawrenceburg Police Department due to the sensitivity and nature of some of the information that will be covered during training. *

    1. yes
    2. no
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field