Thank you for your interest in CERT! First Name * Last Name * Date of Birth * Last Four of SSN * XXX-XX- Address * City * State * Postal Code * Mailing Address (If Different) Primary Phone Number * Secondary Phone Number E-Mail Address * Clubs and Organizations Are you a member of a Neighborhood Crime Watch, Homeowner’s Association, or any other organization/club, please indicate the name of the group and its president: Occupation * Employer * Physical and Medical Restrictions Do you have any physical or medical conditions that might affect your participation in some of the exercises used in this course? If so, please explain: How Long Have You Lived In Massachusetts? * Year(s) Please round to the nearest year How Long Have You Lived In Your County? * Year(s) Please round to the nearest year Military Service * Yes No Have you ever served with any branch of the United States Military? If yes, which branch? Disaster Training * Yes No Do you have any disaster related training or experience? If yes, please explain Medical Training * First Aid CPR EMT LPN Paramedic RN None of the Above Have you ever received training in any of the below? Other Medical Training: Emergency Training * Incident Command (ICS) Fire Fighting Law Enforcement HazMat Fire Suppression Communications Search & Rescue Disaster Preparedness Weather Emergencies Wilderness Survival Damage Assessment Record Keeping Shelter Management Ham Radio None of the Above Have you ever received training in any of the below? Other Emergency Training: Have you ever been convicted of a felony? * Yes No If so, please explain Submittal Acknowledgment * Yes, I agree to the conditions of this form No, I do not agree to the conditions of this form By completing this form, you agree to submit to a complete criminal background investigation and acknowledge the submittal of your CERT application to the Town of Uxbridge, MA. Leave this field blank