Citizen Academy Application

2. Personal Information

4. First Name*

5. Last Name*

7. Address1*

9. Address2

11. City*

12. State*

13. Zip*

15. Home Phone Number*

17. Work Phone Number

19. Employer*

21. Occupation*

23. Email Address

25. Organization Membership Information

27. Have you ever served on a board, commission, or committee for the City of Danville?:*

    1. Yes
    2. No

29. If yes, which one?

31. Please list any civic, professional, business, religious, social, or other organizations of which you are a member. If new to Danville, you may include activities in other communities.

33. Please list organization memberships and positions held*

35. Why are you interested in participating in the Citizen Academy?*

37. Are you interested in serving on a Board, Commission, or Committee?*

    1. Yes
    2. No

39. Do you need any special accommodations in order to participate in this program?

    1. Yes
    2. No

41. If yes, please explain:

43. Optional: To ensure that we reach a cross section of our community, please choose your:

45. Sex:

    1. Male
    2. Female

46. Age

    1. 18-25
    2. 26-39
    3. 40-55

    1. 56-70
    2. 71+

47. Ethnicity

49. Please note that preference will be given to residents who have completed the Citizen Academy.

    Please note that preference will be given to residents who have completed the Citizen Academy.

Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field