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2. First Name*
3. Last Name*
5. Address1*
7. Address2
9. City*
10. State*
11. Zip*
13. Phone Number*
14. Email Address*
15. Birthdate*
    Birthdate
17. Occupation
18. In the Borough of Pottstown I,*
    -- Select One --LiveWorkOwn Property
19. Number of Years*
20. Are you willing and able to attend all class sessions?*

    1. Yes
    2. No
22. Briefly state why you would like to participate in the Citizens Leadership Academy*
24. Are you currently serving on a Committee with the Borough? If yes, which one?*
26. Please describe your interest and experience in community service*
28. What do you hope to get out of the class?*
30. List any medical conditions, medications, or allergies we need to be aware of:*
    Tours may include stairs and extensive walking
32. Driver's License Number*
    For background check purposes only
35. I verify that the information submitted on this application is true and correct.*

    1. Yes

    1. No
37. By submitting this application, I authorize the Borough of Pottstown to conduct a background investigation to determine my suitability for admission to the program.*

    1. Yes

    1. No
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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field