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2. Contact Information (Optional)
4. First and Last Name
6. Street Name and Number
7. Zip Code
9. Telephone
10. E-mail
12. How familiar are you with the benefits of annexing into incorporated city limits?*

    1. Very familiar
    2. Somewhat familiar
    3. Not familiar
14. Rate level of interest in annexing into the city limits of Cocoa*

    1. Very likely
    2. Likely
    3. Unlikely
    4. Not interested
16. Reason for answer*
18. Select one or more of the following:*

    1. I would be interested in attending a presentation by the City of Cocoa regarding annexation, benefits of annexing, and the process of annexation.
    2. I would like a City representative to contact me regarding questions I may have relating to annexation. (Be sure to leave contact information above)
    3. I would like to receive information regarding annexing into the city limits of Cocoa.
    4. I do not wish to participate.
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20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

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