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TOWN OF NORTH SMITHFIELD EMERGENCY MANAGEMENT AND HOMELAND SECURITY
PETER E. BRANCONNIER , DIRECTOR
COMMUNITY EMERGENCY RESPONSE TEAM 2010
CERT APPLICATION
DATE_______________________________
(PLEASE PRINT CLEARLY)
YOUR NAME__________________________________________________________________________
ADDRESS_____________________________________,
STATE_______________ZIP_______________
TELEPHONE ____________(best time to call you)
E-MAIL_________________________________
1) PLEASE TELL US BRIEFLY WHY YOUR ARE INTERESTED IN THE CERT PROGRAM.
______________________________________________________________________________
______________________________________________________________________________
2) HAVE YOU HAD CPR TRAINING? IF YES, CERTIFICATION EXPIRATION DATE: ______________
3. HAVE YOU HAD AED TRAINING? IF YES, CERTIFICATION EXPIRATION DATE: ________________
4. HOW DID YOU FIND OUT ABOUT THE CERT PROGRAM?
___________________________________________________________________________________
5. YOUR
SIGNATURE___________________________________________
RETURN TO: PETER BRANCONNIER, DIRECTOR
TOWN OF NORTH SMITHFIELD EMERGENCY MANAGEMENT
805 POUND HILL ROAD, NORTH SMITHFIELD, RI 02896
(FAX:401-762-5282) (OFFICE: 401-767-2206) (e-mail at nsema@cox.net)