ApplicationThis is a featured page

To request a CERT training class for your group or organization,
contact the Calhoun County EMA at (256) 435-0540.

CALHOUN COUNTY CERT
Full Name:___________________________________________________________Application - Calhoun County CERT
Address:___________________________________________Zip Code:__________
Home Phone:________________________ Other phone:____________________
E-mail:_______________________________________________________________
Drivers License Number:____________________ (Req. by State)
State of Issuance:_________ Date of Birth:_____________________
SSN#:_____________________________ (Optional - May be req. later)
Employer:____________________________________________________________
Employer Address:____________________________________________________
Personal Reference # 1 Name:__________________________________________ Address:_____________________________________________________________
Phone:_______________________________________________________________
Personal Reference #2
Name:_______________________________________________________________
Address:_____________________________________________________________
Phone:_______________________________________________________________
How did you hear about the Calhoun County CERT?______________________ _____________________________________________________________________
What is your purpose of attending?_____________________________________ _____________________________________________________________________
Have you ever had any emergency aid training?__________________________
If so, what?__________________________________________________________
Please circle your golf shirt size: S M L XL XXL

Please print and send to Debbie Blevins, EMA Planner 507 Francis St West Jacksonville, AL 36265
Or email to dblevins@calhounema.org


jgaddy
jgaddy 		Latest page update: made by jgaddy , Jan 10 2008, 8:19 AM EST (about this update About This Update jgaddy Edited by jgaddy

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