Eugene Police Department Cadet Program Application for Membership

2. Application for Membership
   Please complete the following sections.

   Please complete the following sections.

4. Name: Last, First, Middle*

5. Date of Birth*

6. Today's Date*

8. Address*

9. Phone*

10. Alternate phone number

12. Email Address*

14. Have you ever been a police explorer or cadet?*
    -- Select One --Yes ExplorerYes CadetNo

    Please choose one:

15. Have you ever applied to be a Eugene Police Cadet?*

    1. Yes
    2. No

17. Where?*

    If you have been a police explorer or cadet, please indicate where.

19. Do you have a valid driver's license?*
    -- Select One --YesNo

20. License number and issuing state

22. Have you ever been cited or arrested*
    -- Select One --YesNo

    Choose one answer

23. If yes, please explain

27. Education History
    List each school you have attended, the location, course of study and dates attended.

    List each school you have attended, the location, course of study and dates attended.

29. High School*

31. College Information

    If you have attended college, please list school name, location, course of study and dates attended.

32. Other Information

    List any courses, training, special licenses, scholastic honors or other qualifications, which may have a bearing on this position

36. Work history
    Beginning with the most current, list the jobs you have held in the last five years. Include any other experiences related to the position for which you are applying, including any volunteer work.

    Beginning with the most current, list the jobs you have held in the last five years. Include any other experiences related to the position for which you are applying, including any volunteer work.

37. Employment History*

    List employers, job title, complete address, phone number, date hired, date terminated, supervisor's name, reason for leaving the job, and if we may contact your employer

41. References
    Individuals not related to you, who can provide information about your character, work ethic, etc.

    Individuals not related to you, who can provide information about your character, work ethic, etc.

43. Name & Occupation, Phone #, Nature of Association*

45. Name & Occupation, Phone #, Nature of Association*

49. Certificate of Application
    In making this application, I certify that the statements I have made are true,complete and I agree that nay willful false statements or misrepresentations herein, are just cause for rejection of my application or disciplinary dismissal from the post. I hereby authorize the Eugene Police Department advisors of Cadet Post #501 to contact any source to verify and obtain information in assessing my qualifications, including past and present employers, law enforcement agencies and references, unless otherwise specified. In consideration of my acceptance, I agree to conform to the rules and regulations of the Eugene Police Department Cadet Program.

    In making this application, I certify that the statements I have made are true,complete and I agree that nay willful false statements or misrepresentations herein, are just cause for rejection of my application or disciplinary dismissal from the post. I hereby authorize the Eugene Police Department advisors of Cadet Post #501 to contact any source to verify and obtain information in assessing my qualifications, including past and present employers, law enforcement agencies and references, unless otherwise specified. In consideration of my acceptance, I agree to conform to the rules and regulations of the Eugene Police Department Cadet Program.

51. Electronic Signature*

    1. Sign

    By checking this box, I am providing an electronic signature.

Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field