CERT Registration Form

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Please fill out the form below to receive information on CERT Training classes.
Please correct the field(s) marked in red below:

1
First Name
 *
2
Last Name
 *
3
Street Address
 *
4
City
 *
5
State
 *
6
Zip Code
 *
7
Phone Number
 *
Phone Number
8
Email
 *
9
Please list any professional skills or interest that may be useful in the CERT Program.
Please list any professional skills or interest that may be useful in the CERT Program.
10
Please list any other skills not mentioned above.

For more information about the Queen Creek CERT Program, please contact:

Joe LaFortune
Emergency Management Coordinator
Town of Queen Creek
22358 S. Ellsworth Road
480-358-3502
Fax: 480-358-3133
Joe.LaFortune@QueenCreek.org

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