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2. First Name
3. Last Name
5. Address1
7. Address2
9. City
10. State
11. Zip
13. Email
14. Home Phone
15. Cell Phone
16. What's your Facebook name?
18. Optional Information
20. Race
21. Gender
22. Occupation
24. Emergency Information
26. Contact Name
27. Relationship
28. Emergency Contact Number
30. Why do you wish to participate in the Citizen Academy?
31. Signature & Date
    I, the undersigned applicant, certify that the foregoing information is true and complete to the best of my knowledge and belief.
33. Questions? Please call Community Development at 910 938-5286 or email lgray@jacksonvillenc.gov
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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

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