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1. Name

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2. Email

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3. Are you affiliated with any organization? Please indicate:

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4. City/Town of Residence

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5. Gender Identity

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6. Racial/ethnic identity

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7. Age Range

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8. Tell us about your current civic engagement experience

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9. What is a major effort you plan to undertake as a Civic Ambassador?

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10. Why do you think it’s important for you to be a civic ambassador in your city, town or region at this time?

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11. How did you learn about the Civic Ambassadors program?

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12. PLEASE CHECK THE BOX IF YOU AGREE: I understand that the Civic Ambassadors Program is a non-partisan program and affirm that I will not attribute any partisan or political party campaign or related work that I may do as an individual as being part of my Civic Ambassador role. As a Civic Ambassador I will endeavor to work with others for the betterment of my community without regard for their political orientation, affiliation, or beliefs. By checking the box and typing my name below, I am electronically signing this application. (Required.)

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13. Day the application was submitted:

Date

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14. Additional Questions or Comments

T