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CERT Volunteer Application

Please correct the field(s) marked in red below:

Cerro Gordo County Emergency Management Agency

78 S. Georgia Ave Mason City, IA 50401

Name
 *
Name
Date of Birth
 *
Address
 *
Address
Previous Address
 *
Previous Address
How long have you lived in?
 *
How long have you lived in?
Drivers License
 *
Drivers License
Phone
 *
Phone
Employer
 *
Employer
Have you ever been arrested for any offenses other then traffic?
Have you ever been arrested for any offenses other then traffic?
If Yes for what?
 *
If Yes for what?
Will you be able to attend 6 out of 8 classes?
Will you be able to attend 6 out of 8 classes?
What do you expect to gain from attending class?
In case of an emergency
 *
In case of an emergency

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.

Signature of Applicant
 *
Signature of Applicant