CERT Application

(Middle Name Required)

Name:

Address:

City:

State:

Zip:

Phone:

Cell Phone:

Date of Birth:

Driver License #:

Email Address:

Employer:

Employer Address:

Employer Phone:

May we contact your employer? YesNo

List the position you are interested in and any skills you may have.

Have you had any medical history which would limit or prevent you from taking part in any physical exertion?	YesNo
I AGREE TO SUBMIT: To a records search by a law enforcement agency in order to determine if I have any serious criminal record or driving record. ALL INFORMATION WILL BE KNOWN TO LAW ENFORCEMENT ONLY.	YesNo
FURTHER: I will submit, if requested, to fingerprinting and photographing. I understand that I will be operating a completely voluntary capacity. I agree that I will not hold the St. Clair County Office of Emergency Management and/or the County of St. Clair, Michigan, liable for any injuries to me, or any actions taken against me, in pursuit of such voluntary activities.	YesNo

Signature:

Date:

You can also attach your certificate of successful completion of IS 317 here:

Contact Information

Office of Homeland Security / Emergency Management
200 Grand River, Suite 204
Port Huron, MI 48060


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