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2. 

3. Palestine Police Department

   Citizens on Patrol

   Application

4. 

6. Persons wanting to become a member of the Citizens On Patrol (COPs) Program must meet the following criteria:
   
   

   1. Be at least 21 years of age
   2. Submit a completed and approved COP application to the appropriate COP Coordinator by posted deadline prior to attending a COP training course.
   3. Pass CJIS and a background check
   4. Complete the 4 hour COP training course
   5. Possess a valid driver's license (to be able to conduct vehicle patrols)
   6. Ensure their vehicle(s) meet all Texas Motor Vehicle Code legal requirements: -vehicle registration, inspection, proof of vehicle insurance (to be able to conduct vehicle patrols)

8. NOTE: Applicants who have a Concealed Handgun License: COP members are not permitted to carry any type of a firearm with them while involved in any Citizens on Patrol activities.

10. Referred by:
12. Date:
    Date:

16. PERSONAL INFORMATION

18. Last Name*
19. Middle Name (or NMN if no middle name)*
20. First Name & Middle Initial*
22. Have you ever used a maiden/previous name?*

    1. Yes
    2. No
23. First Name

    Enter Maiden or Previous Name

24. Middle Name (or NMN if no middle name)

    Enter Previous Name if Applicable

25. Last Name

    Enter Previous Last Name if Applicable

27. Have you ever used an alias?*

    1. Yes
    2. No
28. Date of Birth
    Date of Birth
29. Driver's License Number
30. State
32. Home Address
34. City
35. State
36. Zip Code
38. Is your mailing address the same as your residential address?*

    1. Yes
    2. No
40. Home Phone*
41. Cell Phone
42. Email
43. Preferred Method of Contact:*
    -- Select One --Home PhoneCell PhoneEmail
45. Country of Birth*

    Required for Background

46. City of Birth
47. Country of Citizenship*

    Required for Background

51. Personal  Information

53. Feet*
    -- Select One --1'2'3'4'5'6'7'8'9'
54. Inches*
    -- Select One --1"2"3"4"5"6"7"8"9"10"11"
55. Weight*
56. Hair Color*
    -- Select One --BaldBlackBlonde or StrawberryBrownGray or Partially GrayRed or AuburnSandyWhiteBlueGreenOrangePinkPurpleUnknown
58. Eye Color*
    -- Select One --BlackBlueBrownGrayGreenHazelMaroonMulticoloredPinkUnknown
59. Gender*
    -- Select One --MaleFemale
60. Race*
    -- Select One --AsianBlackNative AmericanUnknownCaucasianLatino

64. WORK INFORMATION

66. Employer
68. Address
70. City
71. State
72. Zip Code
74. Work Phone

78. BACKGROUND

80. Have you ever been convicted of a crime?*
    -- Select One --YesNo
82. (If "Yes", explain below)

86. REFERENCES

    Provide the names, addresses, and phone numbers of two references.

88. 1. First Name
89. Last Name
91. Address
93. City
94. State
95. Zip Code
97. Phone Number
98. Email Address
100. 2. First Name
101. Last Name
103. Address
105. City
106. State
107. Zip Code
109. Phone Number
110. Email Address
114. PLEASE READ PRIOR TO SIGNING AND RETURNING THIS APPLICATION.*

     I hereby grant the Palestine Police Department permission to conduct a background investigation based on the information given on this application.

     1. I agree.
116. Release of Liability Participation in the Citizens on Patrol-Palestine*

     I agree to assume any and all liability and hold the Palestine Police Department, its officers, employees, and instructors harmless from all claims or actions which I ever had, now have, or may have in the future or any liability for injuries or damages which occur to me as a result of my participation in the Citizens on Patrol-Palestine. I expressly waive all claims for medical expenses, loss of services, or other claims to which I may otherwise be entitled, and I agree to indemnify and hold harmless the Palestine Police Department, its officers, employees, and instructors from all claims made by third parties against it or them which results from my activities with the Citizens on Patrol-Palestine.

     1. I agree.
118. I have read and understood this release*

     and signed it voluntarily and with full knowledge of its significance.

     1. I agree.
120. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
122. Electronic Signature

126. FOR DEPARTMENT USE ONLY

128. 10-29 Check
129. Criminal History Check
130. Fingerprints
132. Officer who conducted 10-29 and Criminal History Check:
134. Signature of Person Approving Application
135. Date
137. Consent for storing submitted data*

     1. Yes, I give permission to store and process my data

139. (Revised August 5, 2021)

Leave This Blank:


141. 1. Receive an email copy of this form.
142. Email address

     This field is not part of the form submission.

143. Submit

* indicates a required field