NI-CERT

Cerro Gordo CERT Volunteer Application

1. First Name
2. Middle Name
3. Last Name
4. Date of Birth
5. Address
6. Apt
7. City
8. Zip
9. Previous Address
10. Apt
11. City
12. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
13. Zip
14. How long have you lived in Cerro Gordo County? (years)
15. Drivers License Number
16. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
17. Home Phone
18. Work Phone
19. Cell Phone
20. Employer
21. Occupation
22. Work Phone #
23. Address
24. City
25. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
26. Have you ever been arrested for any offenses other than traffic? Please Select Yes No
If Yes, for what?
When
Where
27. Will you be able to attend 6 out of 8 classes? Please Select Yes No
28. What do you expect to gain from attending class?
29. In case of an emergency First Name
30. Last Name
31. Phone

I hereby certify that the information contained in this application is true and complete to the best of my knowledge. You hereby authorize to make any investigation of my personal history deemed necessary for consideration to attend the Cerro Gordo County Community Emergency Response Team training.

32. Signature Please type your full name to serve as an electronic signature.
33. Today's Date