WILSON POLICE DEPARTMENT

RIDE ALONG APPLICATION

NAME:__________________________________AGE:_______TELEPHONE (H)_________________

ADDRESS:___________________________________________TELEPHONE (W)________________

DATE OF BIRTH:_______________ SEX:_______

DRIVER’S LICENSE NUMBER:__________________

PREFERRED DATE(S) AND TIME(S) FOR A RIDE ALONG

1st Choice:_________________________________________________________Shift:____________

2nd Choice:_________________________________________________________Shift:____________

3rd Choice:_________________________________________________________Shift:____________

QUESTIONNAIRE

1. Are you currently under the care of a doctor? Yes_____ No_____

2. Are you currently taking any medications? Yes_____ No_____

3. Have you read and understand the quidelines for a

Wilson Police Department Ride-Along? Yes_____ No_____

4. Have you completed a Wilson Police Department Ride

Along General Release Form? Yes_____ No_____

5. Please write a brief summary of your reason(s) for

wishing to ride with a Wilson Police Officer.________________________________________

______________________________________________________________________________

______________________________________________________________________________

Applicant Signature:______________________________________

Authorizing Supervisor/Commander:________________________

Host Officer & Cruiser #:__________________________________

WPD # 63 Rev. 3/04