To complete this section, begin with your present or more recent employer first, and continue in reverse chronological order.
List any traffic convictions for the last five years.
List any traffic crashes for the last five years.
In 150-300 words, describe why you want to enter the field of law enforcement
I respectfully request that you forward to the Town of Normal, Illinois, any and all information that you
have concerning me, my work record, or my reputation. This includes any information that may
appear in my personnel file, criminal conviction records, or other confidential files or records. This
information will be used to determine my qualifications and fitness for the position of Intern I am
seeking with the Town of Normal. I hereby release you and/or your employer from any liability
and/or damage of whatever nature due to the furnishing of such information requested above.
Further, I acknowledge that the internship program typically involves riding in agency vehicles and
participating in policing activities. I realize that such activity involves risk of personal injury or property
damage, and I hereby assume such risk and release and agree to hold harmless the Town of
Normal, the Normal Police Department, their officers, agents and employees from any liability for
civil damages arising out of their actions or the actions of others in connection with this activity. In
consideration of participating in the ride-a-long program, I further covenant and agree, as a condition
of the granting of my internship request, to indemnify and hold harmless the Town or Normal, the
Normal Police Department, their officers, agents and employees from any liability which may be
incurred by them or either of them proximately resulting from any acts or omissions by me during this
activity. I further represent that I am above the age of 18 years, with full understanding of all risks
involved and agree that this release and its indemnity agreement shall be binding upon my heirs,
executors, administrators, and assigns. A copy of this release is as valid as the original
signed REFERENCE RELEASE OF LIABILITY even though the copy does not have my original
By my electronic signature, I certify that I have read and understand the Reference Release of Liability.
I hereby certify that all answers to the above questions are true and I agree and understand that any
false statement contained in this application may cause rejection of this application or termination of
internship, and shall constitute gross misconduct for benefit eligibility. I understand that an incomplete
application may result in a lost internship opportunity.
I authorize the Town of Normal to contact my current and past employers and personnel references
listed above to verify employment, work records, and suitability for internship with the Town, and to
investigate personal, criminal, or other areas, such as personal contact with neighbors, friends, or
others with whom I am acquainted. This inquiry includes information as to my character, general
reputation, personal characteristics,
and mode of living. I understand that my appointment to an internship may be subject to satisfactorily
completing a pre-employment medical exam, including drug and alcohol screen, and that the
truthfulness of the statements in this application may be verified by polygraph examination.
I understand that I will have to provide acceptable documentation attesting that I am a
I understand that this application is not a contract of internship. I understand that any oral or written
statement to the contrary is expressly disavowed, and should not be relied upon by my prospective or
By my electronic Signature, I certify that I have read and understand the statements above.
Please read the Internship Rules as stated on http://www.normal.org/699/Internship.
By my electronic signature, I certify that I have read and understand the Internship Rules.
This field is not part of the form submission.
* indicates a required field