WILSON POLICE DEPARTMENT

RIDE ALONG APPLICATION

 

 

NAME:__________________________________AGE:_______TELEPHONE (H)_________________

 

ADDRESS:___________________________________________TELEPHONE (W)________________

 

DATE OF BIRTH:_______________††††††††††† SEX:_______ †††††††††††††††††††

††††††††††††††† †††††

DRIVERíS LICENSE NUMBER:__________________

 

 

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

 

1st Choice:_________________________________________________________Shift:____________

 

2nd Choice:_________________________________________________________Shift:____________

 

3rdChoice:_________________________________________________________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

 

†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††