NEWPORT BEACH FIRE DEPARTMENT COMMUNITY EMERGENCY RESPONSE TEAM APPLICATION

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

What Community Association or School do you belong to? *

Which CERT Class would you like to take? *

Fall Series

Spring Series

Emergency Contact Information

First Name *

Last Name *

City *

State *

Zip Code *

Phone Number *

EMPLOYMENT DATA

Employer Name

Occupation

Street Address

Type of work preformed

City

State

Zip Code

Phone Number

Email Address

Special Training

First Aid (CPR/AED Certified)

Expiration Date of CPR /First Aid Card +

Languages Spoken Other Than English

Other Training/Skills

Criminal Background

Have you ever plead “guilty”, “no contest,” or have you ever been convicted of any other criminal offense, other than a minor traffic violation? *

If you answered yes to the above question, please indicate what, when and where was the disposition of the offense.

Are you currently out on bail or on your own recognizance pending trail for a recent arrest? *

THE EXISTENCE OF A CRIMINAL RECORD DOES NOT CONSITUTE AN AUTOMATIC BAR. Eligibility for consideration will be based on the nature of the offense and the duties and responsibilities of the program for which you are applying. Omit convictions more than two years old for violations of Cal. Health & Safety Code Section 11357(b) or (a), 11360 (c), 11364, 11365 or 11550 as they relate to marijuana before January 1, 1976, and their statutory predecessors.

CERT Contact Directory

As a member of the Newport Beach Fire Department Community Emergency Response Team (CERT), you have the option of having your contact information included in the City of Newport Beach CERT Volunteer Directory. I understand this information is a public record and may be disclosed to members of the Newport Beach Fire Department and graduates of the Newport Beach CERT Volunteer Program for the purposes of forming CERT teams within my neighborhood.

Do you consent to the CERT Volunteer Directory *

Liability Contract & Code of Conduct

Please upload a signed copy of the Liability Contract

I hereby certify that all the information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that any false statements, misrepresentations, or omissions of fact may be cause for disqualification from volunteering or immediate termination of volunteer service, regardless of when such information is discovered. I declare under penalty of perjury under the laws of the State of California that the information I have provided in this application is true and correct. *

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Name (First, Last) *

Signature Date * +