Municipal Clerk Institute and Academy Data Form

Must be filled out for each registration and sent to Executive Development Center

Fax to 757-683-6082 Attn: Pamela M. Cornell Institute Director

(Registration is a separate process – this is to be done in addition to registration)

 Name (First, Middle, Last) _____________________________________________

 Clerk of ___________________________________________________________

 Street Address _______________________________________________________

 City ________________________ State _________________ ZIP_______________

 Phone day ____________________ Evening _______________________________

 Fax _______________________________ Email ___________________________

 Vegetarian Meal Required? ________

 This is my _____ year at the Institute

 This is my _____ year at the Academy