CERT Community Volunteer Application All information will be treated confidentially. Please answer all question as completely as possible.Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)Emergency Contact(Required) First Last Emergency Contact Email(Required) Emergency Contact Phone(Required)Have you ever been convicted of a felony?(Required)YesNoAre you a registered sex offender?(Required)YesNoAre you affiliated with a group or organization?(Required)YesNoGroup Name Group Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Group Contact Name First Last Group Email Group PhoneWhat days are you available to volunteer?(Required) Monday - Friday Monday Tuesday Wednesday Thursday Friday Saturday Sunday Select AllWhat times are you available to volunteer?(Required) Morning (6am-12pm) Afternoon (12pm-6pm) Evenings (6pm-12am) Nights (12am-6am) Would you be available to assist in preparedness activities/projects?(Required) Yes No How much time do you feel you want to commit to volunteering?(Required) Please reply with details on the numbers of times per week, month or year. Licenses (Drivers & Professional)Licenses Type(Required) License State(Required) License NumberLicense Expiration Date MM slash DD slash YYYY Please Check: I wish to become a trained CERT Member. Will require completing 24 hours of the FEMA CERT curriculum. Yes Please rate your skills in all of the areas that apply to you:AccountingMinimalGood/SatisfactoryAbove Average/ExpertBookkeepingMinimalGood/SatisfactoryAbove Average/ExpertCompleting Forms 1 on 1 (Registration)MinimalGood/SatisfactoryAbove Average/ExpertCommunications (telephone, radios)MinimalGood/SatisfactoryAbove Average/ExpertComputers & Data ManagementMinimalGood/SatisfactoryAbove Average/ExpertCustodial TasksMinimalGood/SatisfactoryAbove Average/ExpertData EntryMinimalGood/SatisfactoryAbove Average/ExpertDesktop Publishing (computer)MinimalGood/SatisfactoryAbove Average/ExpertDetail OrientedMinimalGood/SatisfactoryAbove Average/ExpertDirecting People (Traffic)MinimalGood/SatisfactoryAbove Average/ExpertDirecting Vehicle TrafficMinimalGood/SatisfactoryAbove Average/ExpertEvent PlanningMinimalGood/SatisfactoryAbove Average/ExpertFiling (paperwork)MinimalGood/SatisfactoryAbove Average/ExpertFood Service Preparation for GroupsMinimalGood/SatisfactoryAbove Average/ExpertForeign Language (please specify)MinimalGood/SatisfactoryAbove Average/ExpertInventory ControlMinimalGood/SatisfactoryAbove Average/ExpertLeadership of TeamsMinimalGood/SatisfactoryAbove Average/ExpertMedical TrainingMinimalGood/SatisfactoryAbove Average/ExpertNarration Skills (Presenter)MinimalGood/SatisfactoryAbove Average/ExpertOrganization SkillsMinimalGood/SatisfactoryAbove Average/ExpertPhotographyMinimalGood/SatisfactoryAbove Average/ExpertPublic SpeakingMinimalGood/SatisfactoryAbove Average/ExpertReceptionist/ClericalMinimalGood/SatisfactoryAbove Average/ExpertScheduling ExperienceMinimalGood/SatisfactoryAbove Average/ExpertSecretarial Skills - Office ManagementMinimalGood/SatisfactoryAbove Average/ExpertSign LanguageMinimalGood/SatisfactoryAbove Average/ExpertSupervision/ManagementMinimalGood/SatisfactoryAbove Average/ExpertTelephone SkillsMinimalGood/SatisfactoryAbove Average/ExpertTelevision/Video ProgramMinimalGood/SatisfactoryAbove Average/ExpertTyping SkillsMinimalGood/SatisfactoryAbove Average/ExpertWheelchair TransportingMinimalGood/SatisfactoryAbove Average/ExpertVolunteer ManagementMinimalGood/SatisfactoryAbove Average/ExpertOther skills: Please tell us about your licensure and/or experience in the following areas, if any: Dispensing Pharmaceuticals Gov, EMA, Agency Official Health/Medical Professional Law Enforcement/Security Maintenance/Custodial Medical Physician Medical Triage Working with Special Needs Population Other For any above licenses, please share the state that you are licensed in, the license number and the expiration date:What are your areas of expertise and would you like to volunteer those skills:Is there anything else that you would like us to know that would assist with your placement as a volunteer?I verify that the information I have given herein is current and accurate to the best of my knowledge. I also verify that I have not been convicted of a felony or, with the last 24 months, been convicted of a misdemeanor that resulted in imprisonment. If this information is in complete or untrue I understand that my volunteer assignment will be terminated. Date of application submission: MM slash DD slash YYYY SignatureCommentsThis field is for validation purposes and should be left unchanged. Δ