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2. GENERAL INFORMATION
4. Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Email Address*
13. Contact Number*
17. RESIDENT INFORMATION
19. Residency*

    1. I live within the Town's corporate limits
    2. I live outside of the Town's corporate limits but in the greater Middleburg community
    3. I own a business in the Town of Middleburg
    4. I am employed by a business in the Town of Middleburg
    5. None of the above apply to me

    Check all that apply

21. How many years have you been a Middleburg resident/business owner/employee?*

    1. 1-4 Years
    2. 5-9 Years
    3. 10-14 Years
    4. 15-20 Years
    5. 20-25 Years
    6. 25+ Years
23. PERSONAL INFORMATION
25. Occupation
27. Are you a member of a community or civic organization located in Middleburg?

    1. Yes
    2. No
29. If yes, please list organizations
31. Do you do any volunteer work in Middleburg?

    1. Yes
    2. No
33. If yes, please describe your volunteer work.
35. What do you hope to gain from attending the Middleburg Citizens Academy?*
39. SAFETY AND AGREEMENTS
41. Emergency Contact Name*
42. Emergency Contact Number*
44. Relationship*
46. Agreement

    The Middleburg Citizens Academy is available for participants free of charge.  Participants are required to attend a full day session (at least eight hours) in order to complete the Academy and participate in the graduation ceremony.  By submitting this application, you affirm that if selected as a participant in the Academy, you will attend the day long session.

    In addition, by submitting this application, you certify that the information provided in it is true and complete to the best of your knowledge. 

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

    This field is not part of the form submission.

51. Submit

* indicates a required field