Municipal Clerk Institute and Academy Data Form

Please complete this form for each registration and send to:

The Executive Development Center
College of Business and Public Administration
Attn: Dalaina Williams
Constant Hall, Suite 2101
Norfolk, Virginia 23529
or
Fax to: 757-683-6082   Attn: Dalaina Williams
(Please note registration is a separate process – this is to be submitted 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