Dallas Citizens Academy
Application Form
Applicants must be 18 years of age or older to be considered for the Dallas Citizens Academy. The deadline for
application submittal is September 29,
2017. Applications can be delivered by hand, or can be sent to the City
Manager’s
Office,
Dallas City Hall, 187 SE Court Street, Dallas, Oregon 97338. For questions, please contact the
City Manager’s Office: (503)831-3502.
General Information
Name: _____________________________________________________________________________________________________
Mailing Address: ____________________________________________________________________________________________
Email: ______________________________ Phone Number: ___________________ Cell Number: ______________________
Shirt Size (for free Academy t-shirt) : _______
Academy Information
Tell us why you are interested in participating in the Academy (you can provide this section as attachment):
The Dallas Leadership Academy is scheduled for 6:00-9:00pm on the following dates: October 5 and 19,
November 2, 16, and 30, and December 14. Graduation will be January 2, 2018 at 7:00 pm. Can you commit
to attending each session?
YES NO
If not, please explain why:
The City of Dallas may take pictures of the participants throughout the Academy to use on our social media
sites. Do you agree to allow your photo to be used in this way? A “no” answer will not disqualify you from
participation.
YES NO
I hereby certify that, to my knowledge, the above information is true and correct.
Signature:_________________________________________________________________ Date:___________________________
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