VOLUNTEER CITIZENS OBSERVER PROGRAM APPLICATION:
Applicants must be at least 18 years of age. The Cocoa Police Department seeks to involve qualified adult citizens in the Volunteer Citizen Observer Program (V-COP), without regard to race, sex, age, national origin, religious affiliation, or ethnicity. Applicants with prior felony convictions, recent DUI convictions, or recent illegal drug use will not qualify to serve as VCOPs. The Cocoa Police Department will conduct a criminal records check on all applicants prior to approval. Incomplete or unsigned applications will not be considered.

Name (Last, First, Middle)

Street Address*

City*

State, Zip Code*

Date of Birth*

Home Phone*

Work Phone

Social Security Number*

FL Driver License Number*

Email Address*

Are you a resident of Cocoa?*

YES NO

Are you employed in Cocoa?*

YES NO

If yes, How long?

EDUCATION:

High School Graduate?*

YES NO

GED?

YES NO

College Graduate?

YES NO SOME COLLEGE

Name of High School

Name of College

Degree or Major

Do you speak a second language?

YES NO

If yes, what language?

BACKGROUND

Have you ever been arrested for, convicted of, or cited for any offense other than traffic?*

YES NO

If yes, please explain in detail, listing appropriate dates, charges, places, and action taken.

REFERENCES:

Are you retired?

YES NO

Former Occupation

Present/Previous Employer

Name of Supervisor

Address

Phone

Date Hired

Your Title

Personal Reference

Address

Phone

Relationship

Personal Reference Number 2

Address

Phone

Relationship

MEDICAL INFORMATION

Do you have any physical defects, handicaps, chronic diseases or other disability that would affect your ability to work as a Volunteer Citizen Observer?

YES NO

Do you carry any medication for emergency?

YES NO

Blood Type

Emergency Contact

Emergency Contact Phone

Name of Physician

Physician Phone

SIGNATURE

"I hereby certify that there are no willful misrepresentations, omissions or falsifications in the foregoing statements and answers to questions. I understand that any omission or false statements on this application shall be sufficient cause for rejection for enrollment or dismissal from the Cocoa Police Department Volunteer Citizen Observer Program. I further understand that the Cocoa Police Department will be conducting a thorough background investigation that may include, but not be limited to, any criminal history, employment history, and/or personal references. I also understand that I serve as a V-COP at the pleasure of the Cocoa Police Department and the Chief of Police, and may be removed as a volunteer at any time, with or without cause. I acknowledge that I have no rights to continue to serve as a volunteer, nor do I have any privileges derived or expected from such service."

Applicant Signature (type name)

Date

Return completed application to:
Cocoa Police Department
Volunteer Citizen Observer Program
1226 W. King St.,
Cocoa, FL 32922