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2. Port Orange University Application
   The City of Port Orange is proud to offer a citizens’ academy, “Port Orange University,” which will give citizens a greater insight into the various services and functions of city government. The program will begin on Monday, September 11, 2017, from 6 p.m. until 8 p.m. and will continue each Monday evening at that time for 9 weeks. The only cost to you is a commitment of time.
4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
15. Employer or Business Name
17. Employer Address
19. City
20. State
21. Zip Code
23. Gender*

    1. Male
    2. Female
24. Shirt Size (check one)*

    1. Small
    2. Medium
    3. Large
    4. X-Large
    5. XX-Large
25. Can you attend all classes?

    1. Yes
    2. No
27. Briefly explain why you wish to enroll in Port Orange University and what you would like to gain from the experience.
Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field