Home Citizens Academy Application - Portland

Citizens Academy Application - Portland

FBI Citizens Academy Application
FBI Portland — Spring 2015

Fields marked in red are mandatory. You must enter N/A if not applicable.

Personal Information
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Gender:  


Driver's License Information
U.S. Citizenship:  




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Address/Contact Information
In the event of an emergency, list a relative or close associate who can be contacted:
Employment Information
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Organization Memberships
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Criminal Background Information
1. Have you ever been charged with or convicted of any felony offense?  


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2. Have you ever been charged with or convicted of a firearms or explosives offense?  


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3. Are there currently any charges pending against you for any criminal offense?  


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4. In the last 10 years, have you been arrested for, charged with, or convicted for any offense?  


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Participation in Firearms Demonstration
Is there any reason you cannot participate in a firearms demonstration?  


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Nomination Information
Nominated as a potential candidate for participation in the FBI Citizens Academy program by:  



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Authorization to Conduct Law Enforcement Checks

I hereby authorize the FBI to conduct a standard check of law enforcement records on me. I understand this check will include, but not be limited to, any record of charges, prosecutions, or convictions for criminal or civil offenses. This check will be used for the purpose of the FBI's Citizens Academy Program application process. My consent is valid for three months from the date authorized below. Any information obtained will be used for the purpose of providing clearance to participate in the FBI's Citizens Academy Program.
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By typing my name and dating the above, I acknowledge that I authorize the FBI to conduct law enforcement checks as noted above. Further, I certify that my statements on this form are true, complete, and correct to the best of my knowledge.

 


Privacy Act Statement and Consent

This is to advise you, in conformance with the Privacy Act of 1974, that the collection of this information is authorized under Title 28 U.S.C.533; 28 C.F.R. 0.85; Executive Order 12958, as amended by 13292; 5 U.S.C.552a(e)(10); 44 U.S.C. chapters 21 and 33; 40 U.S.C. chapter 318a; and Title 41 CFR 102-81.10 and 81.15. The furnishing of this information, including your Social Security number, is voluntary on your part and will be used for the purpose of providing clearance to participate in the FBI’s Citizens Academy program. Information you provide will be protected and used in strict compliance with the Privacy Act and the routine uses most recently published in the Federal Register for the FBI’s Central Records System (Justice/FBI-002) and the FBI’s Blanket Routine Uses (Justice/ FBI-BRU). You are not required to execute this form; however, if you do not, this refusal may result in your application for participation in the FBI Citizens Academy program being rejected. Knowingly falsifying or concealing information required on this form will result in your application being rejected. In addition, Title 18 Section 1001 of the U.S. Code provides that knowingly falsifying or concealing a material fact may under certain circumstances constitute a felony resulting in fines and/or imprisonment.

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By typing my name and dating the above, I acknowledge that I authorize and agree with the execution of the above Privacy Act Statement and Consent form.


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For questions, please contact FBI Public Affairs Specialist Beth Anne Steele at Elizabeth.Steele@ic.fbi.gov or (503) 460-8099.

Deadline for Spring 2015 Applications: Wednesday, February 25, 2015