PCAB Application

First Name *

Last Name *

Email Address *

Primary Number *

Phone Type *

Seconday Number

Phone Type

Home Address *

City *

State *

Zip Code *

Are you or have you ever been employed? *

Education Level *

Explain why are you interested in being on the Police Community Advisory Board? *

Are you involved in a Neighborhood Association? *

Do you currently work with any community organizations? *

Emergency Contact Name *

Emergency Contact Last Name *

Relationship to you *

Home Phone

Cell Phone

Work Phone

Fax Number

Email Address

Address *

City *

State *

Zip Code *

By submitting this application, I affirm that I am not a convicted felon and the facts set forth in it are true and complete. I understand that if I am selected as a member of the Midwest City Police Community Advisory Board, my time is voluntary and I will not be compensated monetarily for my service. I also understand the bi-monthly commitment to appear at the Advisory Board meetings, as well as other duties which may be required of me. Additionally, I understand that if I am accepted as an applicant, any false statements, omissions, or other misrepresentations made by me on this application may result in immediate dismissal.

Do you agree to these terms? *

PCAB Application

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