Name of Applicant *

First Name

Last Name

Date of Birth *

(Applicants must be at least 18 years of age.)

MM

DD

YYYY

Applicant is over the age of 18 *

Yes

No

Do you have any criminal offenses above a Class 2 Misdemeanor? *

Yes

No

Phone *

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Background Check Authorization *

I, the above applicant, hereby grant permission to the Culpeper County Sheriff's Office (CCSO) to conduct a background check as part of the Citizens Academy application process. I understand that this background check will be used to determine my eligibility for participation in the program. I authorize the CCSO to obtain and review any information related to my background, including but not limited to, criminal history records, traffic records, and other publicly available information. I hereby certify that, to the best of my knowledge, the provided information is true and accurate.