Irondequoit Police Department Alumni
Association
Application for Membership
Name: _________________________________________________________________
Street:
_________________________________________________________________
City: ________________________________State: ___________ZipCode:
_________
Email: _________________________________________________________________
Day Time Phone: _____________________Evening Phone:
_____________________
Best time to contact you: AM
___________________PM _______________________
Drivers License #: _____________________Non Driver Id #:
____________________
Date
of Birth:
_________________________ Gender: M___________F___________
Social Security #:
________________________________________________________
Have you ever been convicted of:
Misdemeanor
Yes _______ No________
Felony
Yes _______ No _______
If you answered yes to either, please supply charge and date of
conviction below:
Charge:_________________________________________
Date:__________________
This
information will be utilized for a back ground check by Irondequoit
Police Department, prior to acceptance in the Alumni Association.
Your
information will be kept confidential, for IPDs
CPAAA use only, and will not be disclosed or shared with any other person or
group. By signing on the line below, you will be consenting to an IPD
background check and affirm that the information you supplied is accurate to
the best of your knowledge.
Signature:______________________________________________Date:____________