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NATRONA COUNTY EMERGENCY MANAGEMENT (Natrona County)

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Feb. 2020
NATRONA COUNTY EMERGENCY MANAGEMENT
307-235-9205
NATRONA COUNTY SHERIFF’S OFFICE
201 North David Street Casper, Wyoming 82601
ncema@natronacounty-wy.gov
307-235-9252 FAX
Gus O. Holbrook
Sheriff
Stacia Hill
Coordinator
Mark C. Sellers
Under Sheriff
Michael Cavalier
Deputy Coordinator
NATRONA COUNTY VOLUNTEER CREDENTIALED CERT TEAM APPLICATION
The information provided will be held in strict confidence, used for the purpose of determining suitability
to the Natrona County CERT program, and for maintaining an individual volunteer file. The Natrona
County Sheriff’s Office is not obligated to accept volunteer services, and the final discretion for
acceptance into the program will be with the Natrona County Sheriff or designee.
Applicants are required to be a minimum of 18 years of age at time application, have been a resident of
Natrona County for at least 1 year, and have not been convicted of a felony crime. Applicants are
required to submit to a drug screen. Upon acceptance, a Natrona County CERT team member’s status is
subject to continued review.
Please completely fill out the application and submit to the Natrona County Sheriff’s Office, Emergency
Management Division located at 201 N. David St., 2nd Floor, Casper, WY 82601.
Today’s date: ___________________
Personal Information:
Name: ______________________________________________________________________________
(First) (Full Middle) (Last)
Date of Birth: ________________________
Social Security Number: _____________________________
*Note: Your social security number is needed for worker’s compensation and to conduct a
background check.
Wyoming Driver’s License Number: _________________________________________
Feb. 2020
Height: __________ Weight: ___________ Hair Color: _______________ Eye Color: _______________
Blood Type: _______________ Medication Allergies: ________________________________________
Home address: _______________________________________________________________________
Mailing address: ______________________________________________________________________
If you have been at the above address for less than 1 year, please list a previous address: __________
____________________________________________________________________________________
Home phone: _____________________________________ Work Phone: _______________________
Cell Phone: ______________________________ Cell Phone Provider: ___________________________
Email: _______________________________________________________________________________
How long have you been a resident of Natrona County: _______________________________________
Employer: ________________________________________ for how long: _______________________
Please list the vehicles(s) you intend to use for CERT operations:
Vehicle Insurance Company Policy Number
1: __________________________________________________________________________________
2: __________________________________________________________________________________
3: __________________________________________________________________________________
Are you available for training/meetings: Weekday _______________Weekend _____________________
Are you available for emergency call outs: __________________________________________________
Do you have a criminal record: _____________ if yes, please explain: ____________________________
____________________________________________________________________________________
Feb. 2020
Do you have any physical or medical limitations: (if yes, please explain)?
*Note: This information is needed to determine appropriate assignment within the team.
____________________________________________________________________________________
____________________________________________________________________________________
Emergency Contact Information:
Name: ______________________________________________________________________________
(First) (Full Middle) (Last)
Mailing address: ______________________________________________________________________
Home phone: _____________________________________ Work Phone: _______________________
Cell Phone: _________________________
CERT Information:
Why do you want to join the CERT program: _________________________________________________
_____________________________________________________________________________________
Do you have any previous CERT Team experience (if yes, please explain):__________________________
____________________________________________________________________________________
List any related training or classes that you have successfully completed and can provide
documentation/certificates: ______________________________________________________________
Application Submission:
The undersigned states the above information is true and correct. Any falsification of information is
cause for denial of application. I further understand the information provided in this application will
be used for a background investigation to determine eligibility.
Applicants Signature: _____________________________________ Date: ____________________
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NATRONA COUNTY EMERGENCY MANAGEMENT (Natrona County)

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Completed 18 July 2020

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