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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.
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