2. Name (First, Last)
4. Emergency Contact Name and Phone Number
6. Address1
8. City
9. State
10. Zip
12. Personal Cell Phone Number
14. Personal Email Address

    All correspondence will be sent to your new town email address. Staff will contact you via your personal email with the login information once it has been set up. If you already have a town email, the email address will remain the same.

16. If staff needs to reach you between the hours of 8:00 AM and 5:00 PM, which do you prefer:

    1. Town email
    2. Town cell phone
18. How do you prefer your name to read on your business cards, town letterhead: and name plate:
20. Would you like a town-issued cell phone:

    1. Yes
    2. No
22. If so, do you prefer:

    1. Iphone
    2. Android
24. Use of Personal Cell Phone

    1. Yes

    If I check "no" above, I understand that any town business conducted on my personal cell phone is subject to FOIA.

26. Would you like a town-issued ipad?

    1. Yes
    2. No
30. I am available on Tuesday, December 13, 2022 at 7:00 PM to be sworn in as a new member of the Purcellville Town Council:

    1. Yes
    2. No
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