Eastern Idaho CERT Application Form Mail to: CERT Program Manager, Jon Corpany, 150 E. 2nd N. Main, Rexburg, ID 83440 Name: ___________________________________________ Date of Birth: ___________________ Address: _________________________________________________________________________ City: ________________________________State: __________ Zip code: ____________________ Home Phone: ____________________________ Work Phone: _____________________________ Cell Phone: __________________ text msg? Y or N Email: _________________________ List current or past civic/community organization affiliation/s: ____________________________ _________________________________________________________________________________ Place of employment: _______________________________________________________________ Job Title/Position: _________________________________________________________________ Why are you interested in CERT training? _____________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Please list any physical limitations (problems with lifting, physical exertion, etc.): _________________________________________________________________________________ _________________________________________________________________________________ Have you been convicted of a felony? _______________ If yes, please explain: _______________ _________________________________________________________________________________ Emergency contact Information: Name: __________________________________________ Phone number: ___________________ Address: _______________________________City: __________________State/Zip: ___________ The above information is, to the best of my knowledge, complete and accurate. I also understand a back ground check maybe performed.

Applicant Signature: _________________________________________ Date: _________________ (Application is not valid without signature; all lines completed and return of a signed informed consent waiver and release of liability (hold harmless agreement).

Parent / Guardian Signature (if under 18): ___________________________ Date: _____________

Eastern Idaho Citizen Corp/CERT reserves the right to accept or reject any CERT applications