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2. 
3. COMPLETE AND SUBMIT THE BELOW APPLICATION TO JOIN THE AMHERST CERT TEAM!
5. Personal Information
7. First Name*
8. Last Name*
10. Are You Over 18 Years Old?*
    -- Select One --YesNo
12. Street Address*
13. Apartment No.
14. Zip Code*
18. Professional or Special Skills
20. Employer
21. Position Title
23. Select All That Apply

    1. CPR
    2. First Aid
    3. Red Cross

    1. MRC
    2. SAR
    3. Fire Dept.
24. Other Skills Or Relevant Info About You
26. Languages Other Than English
27. Age (you must be at least 14 years of age)*
    -- Select One --1415161718 or Older
31. Contact Information
33. Preferred Phone*
34. Cell Phone
35. Work Phone
37. Email Address
38. Other Contact Information
40. Emergency Contact Name
41. Emergency Contact Phone Number
43. Acknowledge and Agree
45. I agree to the following: *

    1. To participate in required trainings
    2. To agree to a Criminal Offender Record Information (CORI) Check and a Sex Offender Registry Information (SORI) check
    3. To read and abide by guidelines set in the CERT Policy and Procedures
    4. To sign the CERT Code of Conduct
    5. To sign the CERT Confidentiality Agreement
    6. To authorize the verification of the information provided on this form
47. Type Your Full Name Below If Everything Contained In This Form Is Accurate
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field