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2. Thank you for your interest in participating in the 5-On-5 conversation with the Carbondale Police Department. We hope that this conversation provides information that will build relationships for the betterment of our community.

4. Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Email*
13. Telephone (optional)
15. Please select a date of availability:*

    1. April 18, 2023

    1. July 18, 2023

    1. October 17, 2023
17. Please submit five questions you would like to address to law enforcement:
19. 1.*
21. 2.*
23. 3.*
25. 4.*
27. 5.*

29. *Submissions will be reviewed and individuals who are not selected will be placed on an alternate list.

31. If you have any questions, please do not hesitate to contact the Diversity, Equity, & Inclusion Officer:

    Sharonda Cawthon
    (618) 457-3228
    Email Sharonda Cawthon

    
    

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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field