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2. Van Buren County

   Community Emergency Response Team

   Application for Volunteer Participation

4. Full Name - First & Last*
5. Email Address*
7. Address
9. City
10. State
11. Zip Code
13. Home Phone Number
14. Work Phone Number
15. Mobile Phone Number
17. Drivers License/ State ID*
18. Your Profession/Job Title
20. Emergency Contact Name
21. Emergency Contact Phone

25. Do you have any professional or prior volunteer experience in any of the following areas? 

27. Check All That Apply

    1. Administrative/business
    2. Construction/Building
    3. Fire service/Law Enforcement
    4. Legal/Paralegal
    5. Marketing/Public relations
    6. Medical/Emergency Medical
    7. Military
    8. Psychology/Counseling
    9. Other
28. Briefly Describe Your Experience

32. Do you have other training or expertise you could utilize as a CERT member?

34. Briefly Describe

38. What type(s) of work would you be interested in performing as a CERT member?

40. Briefly Describe

44. Do you have any health problems, disabilities, or other circumstances that would prohibit or limit you from fully performing the physical responsibilities of a CERT member?

46. Briefly Describe

50. Typically, what day(s) of the week would you be most likely to serve?

52. Check All That Apply

    1. Any day of the week
    2. Weekdays
    3. Weekends
53. On These days, I'm typically Available

    1. Anytime
    2. Daytime Hours
    3. Nighttime Hours

57. Have you ever been arrested for a misdemeanor or felony? NOTE: A conviction of an offense will not necessarily eliminate you from consideration as a CERT member.

59. Briefly Describe

63. Van Buren County

    Community Emergency Response Team

    Disclosure and Authorization For Background Investigation

65. I,*

    Applicant Printed Name:

67. understand that in connection with my application for participation in the County of Van Buren Community Emergency Response Team (CERT) the County will research and verify information that I have provided. I hereby authorize the County prior to or at any time after my acceptance into the (CERT) program to perform a background investigation. I understand this report may include inquiries regarding my work history, court records, including criminal convictions record as permitted by law, driving history, and references supplied/obtained from professional and personal associates. I hereby authorize employers, educational institutions, consumer reporting agencies, and other persons or entities having information about me to provide such information to the County of Van Buren or entities having information for the County. I fully release the County and hold its employees, officers, directors, agents, successors, assignees, and all other parties involved in the backgrounds/ reference investigations. I understand that my background/reference investigation check results may be used to determine whether to accept/reject the application for participation in the CERT program. I accept that the Disclosure Authorization is not an offer for employment by the County of Van Buren or a contract with the County. I further understand that no representative of the County of Van Buren, CERT representatives, instructor, or other participants in the CERT program has the authority to enter into any agreement for employment for any specified period of time. All participants of the CERT program are considered at-will volunteers and can be dismissed from the program at any time for any reason.

69. Date/Time*
    Date/Time

    Date/Time
71. Applicant First Name*
72. Applicant Last Name*
74. Applicant Address*
76. Applicant City*
77. Applicant State*
78. Applicant Zip Code*
80. Applicant Phone Number*
81. Applicant Email Address*
Leave This Blank:


83. 1. Receive an email copy of this form.
84. Email address

    This field is not part of the form submission.

85. Submit Submit and Print

* indicates a required field