Membership Application

Name

Street Address

City

State

Zip Code

CERT Basic Training Location

CERT Basic Training Date (MM/DD/YYYY)

Skills/Certifications (other than CERT Basic Training)

Phone

With which CERT are you associated?

Name of CERT Program Manager

Program Manager’s Email

Program Manager’s Phone

How did you hear about us?

Other Details

Alternatively you may submit payment of $25.00 by check or money order to the address below.

PO Box 104281

Jefferson City, MO 65110