2010 Citizens Academy Application

Name:
Street Address:
City, State, Zip:
Phone Number:
Email Address:
Your Birthdate:
Are you a U.S. Citizen?	Yes No
Your Driver's License Number and State:
Your Race (optional):	African American Native American White Hispanic Asian
Your Gender (optional):	Male Female
Your Employer:
Your Occupation:
Your Employer's Address and Phone Number:
Organizations or Club Memberships:
How did you hear about the Citizens Academy?
Why are you interested in attending?
Have you ever been convicted of a crime? If so, please give details.

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