SHIELD Application – Apex Forms

Title

First Name*

Last Name*

Phone Number*

Cell Phone

Text?

Yes
No

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Name of Organization, Church or Subdivision

Email Address*

Primary Interest*

Select one primary Interest

Secondary Interests

Choose any other interests that you would like to receive alerts and bulletins about.

Cyber
Education
Emergency Services
Faith-Based
Government
Health Care
Military
Security
Miscellaneous

Why do you want to be a part of the Louisa County Sheriff's Office SHIELD?

Any prior experience to be the SHIELD Coordinator for your organization or group? Please List...

Electronic Signature Agreement*

By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

I agree.

Electronic Signature*

Receive an email copy of this form.

Email address