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2. First Name*
3. Last Name*
5. Address1*
7. City*
8. State*
9. Zip*
11. Primary Telephone #*
12. WorkTelephone #*
14. Email Address*
    (abc@i23.com)
15. Birthday*
    example- 01/01/1234
17. Do you have a Driver's License/State ID?*
    -- Select One --YesNo
18. If yes, what state?*
19. Shirt Size*
    -- Select One --SmallMediumLargeX-Large2X-Large3X-Large
21. Occupation*
22. Employer*
    If Self Employee please type (Self)
24. City*
25. State*
26. Zip*
28. Acknowledge*

    1. Agree
30. Acknowledgement
    By clicking on the Checkbox above you acknowledge that all information is true to the best of your knowledge. You further authorize the Niles Police Department to conduct a background check and understand that any false or misleading information or information found in the background check may disqualify me from consideration int he Niles Citizens Police Academy
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32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field