Community Emergency Response Team
Candidate Application

Last Name:*

First Name:*

MI:*

Date of Birth: mm/dd/yyyy*

Community:*

Home Address:*

City:*

State:*

Zip:

Home Phone:*

Work Phone:

Cell Phone:*

Email:*

Emergency Contact Number:*

Emergency Contact Name:

Relationship to you:*

Physical Condition*

Excellent Good

Fair Poor

List physical disabilites requiring special accommodations: Explain*

What are you hoping to accomplish by participating in the Community Emergency Response Team?

How did you first hear about us?

Why do you want to participate in the CERT Program? *

Career Goals: (State briefly)*

Have you ever been convicted of a felony?*

Yes

No

If yes, explain:

Give name & phone of 2 character references whom are not related nor co-workers:

Name:

Address

Phone:

Name:

Address:

Phone:

Release Authorization

I would like to participate in the College Park Fire Department's Community Emergency Response Team Program. I reside or work in the city of College Park. I do hereby authorize a review and full disclosure of all records concerning myself to any duly authorized member of the College Park Fire Department, whether such records are of a public, private, or confidential nature. The intent of this authorization is to give my consent for full and complete disclosure of all records.

I understand that any information obtained by a personal history background investigation will be used to determine my suitability for selection as a member of the Community Emergency Response Team.
This does not insure me a position as a full time firefighter with the College Park Fire Department.

A photocopy of this release form will be as valid as the original form, even though the photocopy does not contain an original signature. I will abide by the rules set forth by the College Park Fire Department staff.

I have read and fully understand the contents of this Authorization for Release of Personal Information Document.

Signature of Applicant: Type your name here*

Date:(mm/dd/yyyy)

Approved By:

Date: mm/dd/yyyy

Indicate Fire Station # in your community

Your signature indicates that you have also read the attached CERT Liability Waiver

CERT Liability Waiver

Please complete and return to:
College Park Fire Dept./CERT
3737 College Street
College Park, GA 30337
Fax: 404.762.4611 / Phone 404.766.8248