Rider Program Application Approved
Disapproved
Date: Failure to truthfully answer any questions on this application may result in being denied permission to ride. Sector/Area in Which Deputy Submitting Form You Wish to Ride: (If Applicable): Driver’s License Number: Name: Race: Sex: Date of Birth: Address (Street, City, State, Zip): Home Phone: Place of Employment: Work Phone: Email Address: Emergency Contact – Phone: Name: How did you become aware of the Rider Program? Reason for participating in program: Additional Comments: Have you ever been CHARGED or If yes, please explain: CONVICTED of any crime? Yes No With whom do you wish to ride? Applicant’s Signature: This section for Sheriff’s Office use only.
Application Checked By: DESCRIPTOR FILE: QI: 10-1457 (8/08)
Date: QH:
QD: