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.____/____)

____________________ (exp.____/____)

____________________ (exp.____/____)

____________________ (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.