City of Colonial Heights
CERT Training
Registration
Full Name: ____________________________________________________
Address: ______________________________________________________
City: ____________________________ State: ____ Zip: _______________
E-mail Address: ________________________________________________
Home Phone: (____) _____-_______ Cell Phone: (____) _____-_______
Work Phone: (____) _____-_______
Please list any Special Skills or Training you have already received:
(Ex: able to speak Spanish or sign language, certified CPR, etc.)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_____________________________________
CERT Course Date(s): __________________________________________
Please Return Applications to Beverly Brandt either by Fax or E-Mail
Fax Number: (804)
520-9302
E-Mail: brandtb@colonialheightsva.gov
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