Minnesota Public Works Association Leadership Academy Registration Form Please fill out the following form to register for the Minnesota Public Works Association Leadership Academy Certificate. Personal Information First Name Middle Name Last Name Suffix Address 1 Address 2 City State ZIP County Phone Email Current Employer Current Job Title Gender Male Female Date of Birth (Month/Day/Year) Are you a U.S. Citizen? Yes, I am a US Citizen No, I am not a US Citizen If no, are you a permanent resident? Yes, I am a permanent resident. No, I am not a permanent resident. Billing Information (if different than participant information) First Name Middle Name Last Name Suffix Address 1 Address 2 City State ZIP County Phone Email Are you interested in more information about a Master in Public Administration degree from Hamline? Yes, I am interested. No, I am not interested. Verification Please type your full name: Please type today's Date (day/month/year): By checking the box, you are signing this registration form and agree that doing so is the equivalent of your manual signature. For information about certificate programs, please contact Cynthia Johnson, Non-Degree Programs Coordinator. Phone (651) 523-2962, Email email@example.com For billing questions, please contact Hamline Student Accounts, 651-523-3000.