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Community Emergency Response Team (CERT) Application
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Full Legal Name
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Preferred Name
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Phone
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Email Address
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Address
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City / State / Zip
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Date of Birth
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Driver's License Number
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DL State
Emergency Contact
Relationship
Emergency Contact Phone Number
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Why are you interested in participating in the Odessa CERT Basic Training Course?
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Availability
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Availability
Weekdays
Evenings
Weekends
Varies
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Areas of Interest
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Areas of Interest
Preparedness
First Aid
Communications
Search and Rescue
Other
Other Area of Interest
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List relevant certifications, licenses, training, or experience (along with applicable expiration dates) that may be useful during CERT training or future volunteer activities.
Provide two individuals who can speak to your character, reliability, or suitability for participation. Please do not list immediate family members.
Name of Reference One
Reference One Relationship
Reference One Phone/Email
Name of Reference Two
Reference Two Relationship
Reference Two Phone/Email
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