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2. For which position are you applying?*

   1. Block Contact
   2. Co-Block Contact
4. Applicant's Full Name*
5. Date of Birth*
7. Spouse's Full Name (if applicable)
8. Spouse's Date of Birth (if applicable)
10. Applicant's Home Address*
12. Best Contact Phone Number*
14. Applicant's Email Address*
16. By applying for the Block Contact or Co-Block Contact position, you will be acting as a liaison to Dublin Police Services. In this capacity, a certain level of trust by neighbors is paramount. Therefore, the police department will conduct Police Records and a Sex Offender File Check prior to recognizing the applicant as Block Contact or Co-Block Contact. For this reason, applicants are required to complete the requested information and type full name in the box below, which will serve as an electronic signature.
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18. 1. Receive an email copy of this form.
19. Email address

    This field is not part of the form submission.

20. Submit Submit and Print

* indicates a required field