CERT

Title*

First Name*

Middle Name

Last Name*

Home Address*

City*

ZIP*

Home Phone

Cell Phone*

Work Phone

Email Address*

Employer Name and Address (if applicable)

Title or Job Description

I am a resident of (County)*

I am 18 or older*

Yes

Driver License #*

Eye Color*

Height*

DOB*

MonthDayYear

Have You Ever Been Arrested?*

NoYes

When, Where, and the Offense

This program does require physical activity. Do you require any special accommodations to participate in this program? (if yes, Please Explain)

Name and Phone Numbers of person(s) to contact in the event of an emergency*

Why do you want to attend CERT training?

Please provide information about your interests, community involvement, etc.

Submit Headshot photo of applicant

applicant should be only person in picture
Recent, taken in the last 6 months to reflect your current appearance.
Background must be plain white or off-white.
Head must be directly facing the camera with your full face in view.

Photo must be print quality! we will use it to print ID cards

Minimum Dimensions: 2x2 Inches

Please Submit Headshot*

After you select image, you might need to click the up arrow to actually upload the headshot to our server

Upload photo of valid drivers license*

Browse Files

I understand a background check will be conducted on all applicants. I authorize a background check on me based on this application. I give permission for any still photography or video footage in which I may appear to be used for whatever purpose deemed appropriate. I do this voluntarily and with the understanding, there is no remuneration. In addition, I release any involved agencies and jurisdictions from any liability related to this training. All information on the above application is true.

Signature*

Lakewood CERT

Submit Headshot photo of applicant