CERT Preliminary Application

Brecksville-Broadview Heights CERT Team Preliminary application

Please fill in the form below.
Full Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Training Availability

I wish to become a trained CERT Member (requires completion of 20 hours of the FEMA CERT Curriculum)I wish to become a CERT Reserve Volunteer (may receive CERT training if desired, but willing to help as needed)
I am interested in being a member of the following team

MedicalTransporationSecurityEscortTechnologyCommunicationPlanningFinance
DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge. I also verify that I have not been convicted of a felony within the last 24 months, or been convicted of a misdemeanor that resulted in imprisonment. I understand that a background check will be part of the full application to CERT. If this information is incomplete or untrue, I understand that my volunteer assignment can and will be terminated.
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