TOWN OF NORTH SMITHFIELD EMERGENCY MANAGEMENT AND HOMELAND SECURITY
PETER E. BRANCONNIER , DIRECTOR
COMMUNITY EMERGENCY RESPONSE TEAM
CERT APPLICATION
DATE_______________________________
(PLEASE PRINT CLEARLY)
YOUR NAME__________________________________________________________________________
ADDRESS_____________________________________, STATE_______________ZIP_______________
TELEPHONE __________________________________ 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)