Community Emergency Response Team

2. First Name*
3. Last Name*
5. Date of Birth*
6. Have you taken a CERT class before?*

   1. Yes
   2. No
   3. I'm not sure
8. Address1
10. Address2
12. City
13. State
14. Zip
16. Phone Number*
17. Email Address*
19. Preferred contact method
    -- Select One --PhoneEmail
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

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