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2. Today's Date*
4. Applicant's Last Name*
5. First Name*
6. Middle Initial
8. Date of Birth*
9. Are you a United States citizen?

   1. Yes
   2. No
10. If not, what country are you a citizen of?
12. Complete Home Address*
13. Mailing Address (if different)
15. Primary Phone Number*
16. Secondary Phone Number*
17. Work Phone Number
19. Email*
21. Name of College*
23. Degree you are working towards*
25. Practicum Instructor's Name*
26. Practicum Instructor's Contact Number*
28. Hours Needed*
29. Date hours must be completed by*
30. Days and number of hours per day you are available.*
32. Career Goals/Skill Development*
    Please provide a brief summary of your career goals and why you believe an internship/practicum at the Farmington Police Department will help develop the skills needed to meet those goals?
34. Do you have a valid driver's license?*

    1. Yes
    2. No
35. If yes, what state?*
37. Have you received any traffic or criminal citations in the last five years?*

    1. Yes
    2. No
38. If yes, list all offenses, dates, locations, agencies of issuance and disposition of each.*
40. Have you ever been arrested and/or convicted of a misdemeanor or felony crime?*

    1. Yes
    2. No
41. If yes, list all offenses, dates, locations, agencies of issuance and disposition of each.*
43. Do you use, have you used or experimented with any illegal drugs, including marajuana, in the last three years?*

    1. Yes
    2. No
44. If yes, provide circumstances, specific dates, illegal drug, and number of times used.*
46. Please provide three references (NO relatives). At least one should be an employer or instructor.
48. Name (First & Last)*
49. Association*
51. Address (street, city, state, zip)*
52. Phone #*
53. Years Known*
55. Name (First & Last)*
56. Association*
58. Address (street, city, state, zip)*
59. Phone #*
60. Years Knonw*
62. Name (First & Last)
63. Association
65. Address (street, city, state, zip)*
66. Phone #*
67. Years Known*
69. It is standard procedure as part of the Farmington Police Department's Internship/Practicum Program, to submit each applicant to a minimal background check. The suitability of new interns/practicum students is of great importance due to the nature of the work and connection as a representative of the Farmington Police Department. It is vital as a representative of the Farmington Police Department and the City of Farmington that interns/practicum students hold themselves to a much higher standard. Therefore, adherence to the department's established policies, procedures, and ethical code is of the utmost importance at all times, if successful in the application process.
71. Applicant's Signature*
    By providing an electronic signature, I am stating that the information provided is true and correct.
72. Date*
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74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit Submit and Print

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