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2. First Name*
3. Middle Name*
4. Last Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Phone Number*
13. Driver's License Number*
15. Email Address*
17. Are you a resident of the Town of Farmville, Prince Edward County, or Cumberland County?*
    -- Select One --YesNo
19. Are you employed in or are you a member of a community or civic organization in the Town of Farmville?*
    -- Select One --YesNo
21. If yes, where are you employed or to what community or civic organization do you belong?
23. I hereby authorize that a criminal history and DMV check be conducted on my name in reference to the Citizen's Academy.*

    1. Yes
    2. No
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

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