Mercyhurst North East Municipal Police Training Academy Application

Personal Information

First Name

Middle Name

Last Name

Address

Country

Street

City

Region

Postal Code

Home Phone

Cell Phone

Birthdate

Email Address

Social Security Number

Marital Status

Gender

Male

Female

Another

Height

Weight

Eye Color

Hair Color

Driver's License No.

Driver's License No. Issued By Which State

Are you a U.S. citizen? (U.S. citizenship is a requirement)

Yes

No

Education

High School Name/Address

Date of Graduation

OR

Date of GED

College/Institution Name

Degree Obtained

Criminal History

Have you ever been arrested for a crime of misdemeanor or above?

Yes

No

Explain In Detail

Are you presently on probation or ARD?

Yes

No

Explain In Detail

Health History

Are you taking any prescription medication(s)?

Yes

No

Name of Medication(s), Dosage and Reason

Do you carry anti-allergy medication with you?

Yes

No

Name of Medication and Dosage

Have you ever been involuntarily (302) committed for an emotional or psychological condition?

Yes

No

Are you pregnant

Yes

No

Veteran Status

Are you a veteran?

Yes

No

Start Date of Service

End Date of Service

Branch of Military

Will you apply for VA Benefits?

Yes

No

Emergency Information

In the event of an emergency, who should be notified?

Name

Relationship

Phone

Physician

Phone

Is your driver's license presently valid, clear and free of any violations, penalties, suspensions, revocations or restrictions for operating a vehicle?

Yes

No

Explain

Responses to the following questions will determine an individual's eligibility to carry a firearm and obtain certification.

1. Have you ever been arrested or charged with a violation of the law?

Yes

No

Explain (indicate all arrests and citations including traffic violations and dispositions)

2. Have you ever been convicted of a crime enumerated in the Pennsylvania Uniform Firearms Act, § 6105(b)? (Crimes listed under § 6105(b) are below.)

Yes

No

3. Have you ever been convicted of driving under the influence of alcohol or a controlled substance on three or more occasions within a five-year period?

Yes

No

4. Are you an individual who has been adjudicated delinquent by any court for conduct which, if committed by an adult, would constitute one of the crimes code sections below in § 6105(b)?

Yes

No

a. Are you an individual who has been adjudicated delinquent by any court, as a result of conduct which would constitute an offense enumerated under §6105(b) of the Pennsylvania Uniform Firearms Act?

Yes

No

b. Has it been 15 years since the delinquent adjudication?

Yes

No

c. Are you 30 years of age or older?

Yes

No

5. Are you a United States Citizen?

Yes

No

Enter immigration identification number

6. Are you subject to an active protection from abuse order, which provides for the confiscation of firearms during the period of time the order is in effect?

Yes

No

7. Have you ever been convicted of a misdemeanor crime of domestic violence? (The conviction must be misdemeanor-graded official and have, as an element, the use of attempted use of physical force, or the threatened use of deadly weapon, committed by a current or former spouse, parent, or guardian of the victim, by a person with whom the victim shares a child in common, by a person who is cohabiting with or has cohabited with the victim as a spouse, parent, or guardian, or by a person similarly situated to a spouse, parent, or guardian of the victim.)

Yes

No

8. Are you a fugitive from justice?

Yes

No

9. Have you ever been adjudicated as an incompetent or been involuntarily committed to a mental institution for inpatient care and treatment under §§ 302, 303, or 304 of the Pennsylvania Mental Health Procedures Act (the Act of July 9, 1976. p.l. 817, no. 143)?

Yes

No

§ 6105a:
Prohibits persons convicted of any of the following offenses under 18 PA.C.S. from possessing, using, controlling, transferring, manufacturing, or obtaining a license to possess, use, control, transfer, or manufacture a firearm in the Commonwealth of Pennsylvania. A conviction includes a finding of guilty or the entering of a plea of guilty or nolo contendere. Whether or not judgment has been imposed, as determined by the Law of the Jurisdiction in which the prosecution was held. The term does not include a conviction which has been expunged or overturned or for which an individual has been pardoned unless the pardon expressly provides that the individual may not possess or transport firearms.

§ 6105b:
§ 908 Prohibited Offensive Weapons
§ 911 Corrupt Organizations
§ 912 Possession of Weapon on School Property
§ 2502 Murder
§ 2503 Voluntary Manslaughter
§ 2504 Involuntary Manslaughter, if the Offense is Based on the Reckless Use of a Firearm
§ 2702 Aggravated Assault
§ 2703 Assault by Prisoner
§ 2704 Assault by Life Prisoner
§ 2709 Harassment and Stalking, if the Offense Relates to Stalking
§ 2901 Kidnapping
§ 2902 Unlawful Restraint
§ 2910 Luring a Child into a Motor Vehicle
§ 3121 Rape
§ 3123 Involuntary Deviate Sexual Intercourse
§ 3125 Aggravated Indecent Assault
§ 3301 Arson & Related Offenses
§ 3302 Causing or Risking Catastrophe
§ 3502 Burglary
§ 3503 Criminal Trespass, if Offense is Graded Felony of Second Degree or Higher
§ 3701 Robbery
§ 3702 Robbery of Motor Vehicle
§ 3921 Theft by Unlawful Taking or Disposition, Upon Conviction of the Second Felony Offense
§ 3923 Theft by Extortion, When the Theft is Accompanied by Threats of Violence
§ 3925 Receiving Stolen Property, Upon Conviction of the Second Felony Offense
§ 4906 Relating to False Reports to Law Enforcement Authorities. If the Fictitious Report Involved the Theft of a Firearm in Section 4906(c)(2)
§ 4912 Impersonating a Public Servant, if the Person is Impersonating a Law Enforcement Officer
§ 4952 Intimidation of Witnesses or Victims
§ 4953 Retaliation Against Witness or Victim
§ 5121 Escape
§ 5122 Weapons or Implements of Escape
§ 5501 Riot, if Offense Relates to Firearm or Other Deadly Weapon
§ 5515 Relating to Prohibiting of Paramilitary Training
§ 5516 Relating to Facsimile Weapons of Mass Destruction
§ 6110.1 Possession of Firearm by Minor
§ 6301 Corruption of Minors
§ 6302 Sale or Release of Weapons or Explosives

If any information is found to be false or in any way a misrepresentation of the applicant, your application will be denied. If any information is found to be false, after having been entered into an Academy class, you may be subject to expulsion and criminal charges.

I hereby authorize the Mercyhurst University Municipal Police Training Academy to investigate and/or verify any and all information contained on this application through whatever means it deems necessary. I will accept any consequences in the event of findings of false information.

In place of your signature, please type your full legal name

Mercyhurst University

Mercyhurst North East Municipal Police Training Academy Application

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