City of Bartlesville 2024 Citizens Academy

Applications may be filled out and submitted below.

Citizen's Academy Application

Full Name(Required)

First Middle Initial Last

Other name used, if applicable

Date of Birth(Required)

MM slash DD slash YYYY

Email Address(Required)

Address(Required)

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Home Phone(Required)

Work Phone(Required)

Have you ever been arrested for a violent crime?(Required)

Yes

No

Place of Employment(Required)

Occupation(Required)

Place of Employment Address(Required)

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Why do you want to be a part of the Citizen’s Academy?(Required)

I certify that all statements made on this application are true and complete. I authorize any individual, company, organization or institution to release any and all information concerning statements made by me on this application, and do hereby release all parties and individuals connected therewith from all liabilities for any damages whatsoever incurred in furnishing such information. I agree and understand that any deliberate misstatement or omission of material facts may disqualify me to attend the Bartlesville GOV Citizen’s Academy. My signature below acknowledges my understanding and agreement with the material provided.

Signature(Required)

Email

This field is for validation purposes and should be left unchanged.

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