Action Center / CERT Application / Florissant, Missouri

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Carefully answer each question accurately. An applicant may be disqualified from attending the C.E.R.T. Training if he/she intentionally makes a false statement of material fact or practices or attempts to practice any deception or fraud in this application.

You can either complete this form online, or print off a pdf version and bring it to the Florissant Police Department. The paper form can be found here: CERT Application

* Denotes a required field

Full Name Middle initial*

List all other names you have used, including maiden names, nicknames and aliases:*

Please Do Not Complete The Following Field

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Home Phone*

Phone Area Code-Phone 3-Phone 4 ext Extension

Cell Phone*

Phone Area Code-Phone 3-Phone 4 ext Extension

Occupation*

Employer*

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Employer Phone*

Phone Area Code-Phone 3-Phone 4 ext Extension

Social Security Number*

SSN 1-SSN 2-SSN 3

Date of Birth*

MonthDay Year,

Age*

Sex*

Male Female

Are you a U.S. Citizen*

Do you have a valid Driver License*

Yes No

State Issued*

Driver License Number*

Expiration Date*

MonthDay Year,

Contact Email*

Whom should we contact in case of an emergency? Name*

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Emergency Contact Phone*

Phone Area Code-Phone 3-Phone 4 ext Extension

Have you ever been arrested, detained or taken into custody in this state, any other state, in the military, or any other entity for any reason at all?*

Yes No

If yes, please explain: Indicate the date, violation charged, location, court disposition, police agency involved, and report (case) number of incident. A record check will be completed on each applicant.

Completed forms may be dropped off or mailed to the Florissant Police Department. Applications will be kept on file and you will be contacted on the next available class.

CERT Application

Completed forms may be dropped off or mailed to the Florissant Police Department. Applications will be kept on file and you will be contacted on the next available class.

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