City of Manassas Fire and Rescue Department
Community Emergency Response Team
Membership Application
9324 West Street Suite 103
Manassas, Virginia 20110
703-257-8458
Applicant Information
Name:
Address:
City:
Zip:
Telephone:
Date of Birth:
E-mail:
Employment Information
Current Employer:
Employer Address:
City:
Zip:
Telephone:
Position:
Emergency Contact
Name:
Address:
City:
Zip:
Telephone:
Relationship:
Criminal Background
Have you ever been convicted of a crime: ____ Yes ____ No If YES, Please explain:
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
You may omit any offense for which the record has been sealed or expunged by the Court.
Note: A Comprehensive Criminal History (CCH) report will be obtained from the Virginia State Police.
Special Skills & Interests
Special skills:
___ EMT
___ Paramedic
___ RN or LPN
___ MD or DO
___ Firefighter
___ Law Enforcement Officer
___ Other medical training
___ Firefighter
___ Grant writing
___ Procurement
___ Webpage design
___ Database design
___ Marketing
___ Advertising
___ Volunteer recruitment
___ GIS mapping
___ Search and Rescue
___ Public speaking
___ Instructor
___ Training development
___ Animal care
___ Emergency shelter
___ Traffic control
___ Public event planning
Other:
________________________________
________________________________
________________________________
________________________________
City of Manassas Fire and Rescue Department – Community Emergency Response Team
City of Manassas Fire and Rescue Department
Community Emergency Response Team
Membership Application
I, ________________________________________________, hereby certify that all statements made in this
application are true. I understand that my misstatement, misrepresentation, material
omission, or falsification of facts shall cause forfeiture of all rights to volunteer service with the
City of Manassas CERT-Fire Corps program. I understand that all information on this
application is subject to verification.
I agree to abide by and comply with all rules, regulations, policies, and practices of the City of
Manassas CERT program. I understand that my volunteer service with the City of Manassas
CERT program is at will, that I have the right to terminate my volunteer service at any time
with or without cause, and that the City of Manassas CERT program has the same right.
I understand that as a volunteer, I have no job status and no right to employment.
I realize that certain areas of government business may involve information or documentation
which is confidential or which is exempt from public disclosure. I agree, that should I ever
receive or otherwise become privy to said information or documentation, that I shall maintain
the same in a confidential manner and that I shall not disclose the whole or any segment
thereof to any other person or entity.
I certify that I am of sound mind, and that I have reached at least my eighteenth (18) birthday
preceding the execution of this Letter of Understanding or if under eighteen (18) my
parent/guardian has approved my volunteer service as evidenced by their signature below.
I certify that I am physically fit to perform the work assigned. If I am unable to perform a
particular assignment due to any limitations, I will immediately contact the Deputy Emergency
Management Coordinator to discuss any accommodations that may be necessary.
_____________________________________________________ _________________________
Signature Date
Received by CMCERT:
_______________________________________________________ __________________________
Signature Date
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