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PVPD Citizen's Academy

  1. Prescott Valley Police Badge
  2. Prescott Valley Police Department Citizen's Academy

  3. Last, First, Middle 

  4. Number/Street, City, Zip Code 

  5. Yes/No

  6. Last, First

  7. Authorization for Release of Information

  8. I, _________________________________________, DO HERBY AUTHORIZE any and all persons, employers, partnerships, corporations and all civilian and government entities, military agencies, law enforcement agencies, private, and city, county, state and federal entities to release, furnish and exchange, any and all available information relating to me for the purpose of determining my suitability to attend a voluntary Citizen's Police Academy for the Town of Prescott Valley Police Department. This includes, but is not limited to, all information related to my employment, performance, disciplinary history, character, integrity, reputation, conduct, behavior, and fitness for duty. 

    This authorizes release to the Town of Prescott Valley Police Department. this release is in addition to, and not intended to curtail or diminish, the authorization and immunity providing by statue. I DO HEREBY RELEASE from any and all liability, all persons or entities disclosing information pursuant to this release. 


    Signature:_______________________________________________


    Date:__________________________

  9. STATE OF ARIZONA

    County of Yavapai

  10. Subscribed and sworn to (or affirmed) before me this ________ day of _____________, 20__,


    By _________________________        


    Notary Public ____________________________________

    My Commission Expires __________________________

    (Seal)



    Please note that we can not witness and notarize a single document. 

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  12. This field is not part of the form submission.