<p> Appendix D – APPLICATION FORM</p><p>APPLICATION FORM - CITIZENS’ ACADEMY 2016 </p><p>The information you supply will be used by West Mercia Police to assess your suitability to participate in the 2016 Citizens’ Academy at Worcester Police Station, West Mercia Police Headquarters and other locations, and will be subject to security checks and vetting procedures. You will be asked to bring proof of identity with you to registration on the first day of the course.</p><p>Title Mr/Mrs/Ms/Miss/Other (Delete as appropriate) Surname/family name First name Middle names Maiden/former names(s)</p><p>Current address</p><p>Postcode Nationality Date of birth Age Email address Home phone number Mobile phone number Daytime phone number</p><p>Warwickshire/West Mercia Police welcomes applications from people with disabilities and from all backgrounds. We will ensure that reasonable adjustments are made wherever necessary to facilitate your participation.</p><p>Do you have a disability, health issue or If you are a commonwealth citizen or foreign special requirement that we should be aware national, is your stay in the UK free of of? restrictions? Yes - please provide details below Yes No No Are there any charges or summons presently Are you or have you ever been a member of the outstanding against you? British National Party or similar organisation Yes - please provide details below whose constitution, aims, objectives or No pronouncements may contradict the Police’s duty to promote race equality? Yes - please provide details below No</p><p>Have you ever been convicted for any offence or had formal cautions, reprimand or warnings by Police for any offences or any bindovers imposed by any court? (Please include traffic convictions and appearances before a court martial, any cautions as a juvenile and spent convictions under the Rehabilitation of Offenders Act 1974) Yes - please provide details below No</p><p>Please write a paragraph detailing why you want to engage with the Citizen’s Academy.</p><p>Declaration</p><p>I declare that all the information provided on this application form is true and complete to the best of my knowledge and belief, and that no relevant information has been withheld. I agree to notify changes or additions in the information I have provided on this form. I understand that if I have knowingly made a false statement or deliberate omission in the information I have provided on this form, my application to the Citizens’ Academy will be terminated. I give my permission for West Mercia Police to use the data I have supplied on this form for the purpose of security checks and vetting – in relation to this application. I commit to attend the full ten-week course, subject to unforeseen circumstances preventing my attendance.</p><p>Signature Date </p><p>Data Protection Act 1998 The information you have supplied is governed by the Data Protection Act 1998 and will be used for the purpose of administering this application.</p><p>Please return your completed application form to:</p><p>SouthWorcsCitizensAcademy @westmercia.pnn.police.uk The form can also be handed in at your local police station.</p><p>Closing date for completed applications is Thursday 12th November 2015</p>