SEMA

Southborough Emergency Management Agency

21 Main Street , Southborough , MA 01772

508-485-3235 – naspesi@southboroughma.com

Community Emergency Response Team

Application

This application is to officially sign up for the Southborough CERT program.

Please print clearly.

(Please return completed applications to SEMA via delivery, e-mail or mail)

Name____________________________________________

Address__________________________________________

City_____________________ State____ Zip Code_______-_____

Contact Information-

Telephone: (Please not which is the best number to contact you at)

Daytime (____)____-_______

Nighttime (____)____-_______

Home (____)____-_______

Business (____)____-_______

Cell (____)____-_______

Other (____)____-_______

Main Email ______________________________________

Alt Email ______________________________________

What is your primary profession and where do you work?

_________________________________________________

List any other professions currently in or held in the past?

_________________________________________________________

Medical Training (if any) and Expiration date:

____________________ (exp.____/____)

Special Training (if any)

___________________________________________________________

HAM Radio Operator? Yes / No

If yes, HAM Operator License # and Class__________________________

Do you speak any other languages? Yes / No

If yes, which language(s) ___________________________________

Do you have any special Skills or Knowledge (i.e. Diver, Accountant, Structural Engineer?

_____________________________________________________________

Do you own a 4 wheel drive vehicle? Yes / No

Does this vehicle have a plow? Yes / No

Other optional equipment: _________________________________________________

Do you own any other recreational vehicles, such as boats, snowmobiles, Etc.? Yes / No

If yes, which vehicle(s) and how many? ________________________________

________________________________________________________

Please list any other information or skills that you would like to share:

_____________________________________________________________

Please provide any additional information not listed above, or attach supplemental documents to application.

____________________________________________________________

Have you ever been convicted of a felony? Yes / No

If yes, please explain: _______________________________________________

________________________________________________________________

Note:

Before acceptance into CERT, all applicants will be required to fill-out a Criminal Offender Record Information (CORI) request form and pass a CORI background check through the Massachusetts Criminal History Systems Board.