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3. 
5. All information provided in this form is subject to Freedom of Information Act requests subject to State law.
7. Applicant Information
9. Last Name*
10. First Name*
11. Middle Name*
13. Today's date*
14. Phone Number*
15. Email*
16. Under 18?*

    1. Yes
    2. No
18. Address*
20. City*
21. State*
22. Zip Code*
23. Length of time at address*
25. Check one:*

    1. Initial application/Never applied

    1. Reapplying

    1. Information update
27. Date last applied:*
29. How did you find out about the Westland Explorers:*
31. Employment Information
33. Current employer*
35. Employer address*
37. City*
38. State*
39. Zip Code*
41. Phone Number*
42. Email Address*
43. Fax Number*
45. Position*
46. Length of employment*
47. Hours per week*
49. School Information
51. Current School*
52. GPA (if in HS)*
54. Previous school(s)*
56. Were you ever suspended or expelled from school?*

    1. Yes

    1. No
58. Please explain*
60. Emergency Contact (Parent/Guardian if under 18)*
62. Address*
63. Phone Number*
65. City*
66. State*
67. Zip Code*
68. Relationship*
70. References
72. Name (Last, First)
73. Relationship
74. Phone
76. Name (Last, First)
77. Relationship
78. Phone
80. Name (Last, First)
81. Relationship
82. Phone
84. Background Information
86. Do you have a Michigan drivers license?*

    1. Yes

    1. No
88. Do you have or did you ever have a drivers license in any other state?*

    1. Yes

    1. No
90. Was your drivers license ever suspended/revoked/denied?*

    1. Yes

    1. No
92. List all traffic violations (if any) (Date, Agency/City, Violation)*
94. Were you ever charged and/or arrested for a crime?*

    1. Yes

    1. No
96. Description of the incident. Include date and location (City, State)*
98. Were you ever contacted by police as a suspect, witness or a victim?*

    1. Yes

    1. No
100. Description of the incident. Include data and location (City, State)*
102. Questions
104. Why do you wish to become a Westland Police Explorer?*
106. Why do you think you should be selected to be a Westland Police Explorer?*
108. What have you heard about the Westland Police Explorer Program?*
110. Signature
112. 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.
114. Signature of applicant*
115. Date*
     Date
117. 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.
119. Signature of parent/guardian if under 18*
120. Date*
     Date
Leave This Blank:


122. 1. Receive an email copy of this form.
123. Email address

     This field is not part of the form submission.

124. Submit

* indicates a required field