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Government Citizens Academy Application

2. Applicant Name*

4. Applicant Address*

6. City*

7. State*

8. Zip Code*

10. Applicant Phone*

11. Applicant Email*

13. You will automatically receive the county's eNewsletter, Weekly Update, and information about your district.

    You will automatically receive the county's eNewsletter, Weekly Update, and information about your district.

17. Are you a current or former employee of Chesterfield County?*

    1. Yes

    1. No

19. If yes, indicate the department name

21. In which Magisterial District do you live?*

    1. Bermuda
    2. Clover Hill
    3. Dale

    1. Matoaca
    2. Midlothian

25. Government Citizens Academy

27. Indicate your first choice of when you would like to attend the Government Citizens Academy*

    1. Spring

    1. Fall

29. What is your interest in the Chesterfield County Government Citizens Academy and what do you hope to learn from attending?

33. Emergency Contact

35. Emergency Contact Name

37. Emergency Contact Phone

39. Acknowledgement*

    I acknowledge video and still photos will be taken during the academy and may be used in county promotions.

    1. Yes
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field