North Las Vegas Block Captain

NORTH LAS VEGAS POLICE DEPARTMENT
NEIGHBORHOOD WATCH
COORDINATOR/BLOCK CAPTAIN APPLICATION
To apply as a Block Captain, fill out this application. Then take the application, a valid state issued driver’s license,
identification card, or Military I.D. to the NLV Police Department Fingerprint/Work Permit Bureau, located at 1301 E.
Lake Mead Blvd. (on the corner of Lake Mead & Bruce Street). HOURS FOR PROCESSING ARE MONDAY
THRU FRIDAY. 8:30 A.M. TO 4:00 P.M. ***Pleas e no te, M ondays
& Fridays te nd to be bus ier days at the W ork
Card B ureau , so you m ay prefer to go on T uesd ay, We dnes day, or Th ursda y.
NAME :____________________________________________________________________________________________
Las t
First
Middle
ADDR ESS: ________________________________________________________________________________________
Street
North Las Vegas, NV _____________________________ PHON E #: (702)_____________________________________
Zip Code
E-MAIL ADDRESS :_________________________________________________________________________________
SUBDIVISION/NEIGHBO RHO OD N AME: _______________________________________________________________
Birthdate:____________
Hair: ____________
SSN: ______ -_____-_____
Eyes: ______________
Race: ___________
Sex: ______ ______
Height: _____________
W eight: ____________
PLACE O F BIRTH:__________________________________________________________________________________
City
State
Coun try
HAVE YOU EVER BEEN ARRESTED OR CITED FOR ANY OFFENSE (EXCLUDING SPEEDING AND PARKING
VIOLA TIO NS)?
YES _________
NO _________
IF YES, PLEASE LIST ALL ARRESTS:
YEAR
OFFENSE
ARRESTING AGENCY
CITY/STATE
DISPOSITION
BY SIGNING BELOW, I AUTHORIZE THE NORTH LAS VEGAS POLICE DEPARTMENT TO CONDUCT A CRIMINAL BACKGROUND
CHECK & INVESTIGATION:
SIGNATU RE: ______________________________________
DATE: __________________________
(Spa nish A pplication Ava ilable U pon Req uest)
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