Thank you for your interest in City of Fort Lauderdale's Explorer Program.

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Date of Application (MM-DD-YYYY):

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Date of Application (MM-DD-YYYY):

Personal Information:

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Personal Information:

Last Name:

First Name:

Middle Name:

Address:

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Address:

Number and Street:	Apt. Number:	City:
State:(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip:

Phone Contact Information (provide at least one contact phone number)

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Phone Contact Information (provide at least one contact phone number)

Primary:ext.

Alternate:ext.

Email:

Email:

What is your gender? (optional)

What is your gender? (optional)

Male

Female

What is your race? (optional)

What is your race? (optional)

Age Verification

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Age Verification

Date Of Birth

Age:

Current School Grade

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Current School Grade(Select an Answer) Select an Answer 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade College

Name of High School Attended

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Name of High School Attended

How did you learn about us?

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How did you learn about us?

Magazine

Radio

Website

School

Recruiter

Other If other, type text here.

Please fill out form completely, all answers mandatory unless optional indicated.

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