Civic Ambassador Application

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* 1. Name

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* 2. Email

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* 3. Affiliated Organization

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* 4. City/Town of Residence

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* 5. Gender Identity

Male (Cis)

Female (Cis)

Not listed (please specify)

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* 6. Race Ethnicity

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* 7. Age Range

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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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. 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 my application.

I agree

Please write your name and date (mm/dd/yy)

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* 11. Additional Questions or Comments