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Community Emergency Response Team (CERT) Training
Please take a moment to complete this form.  Thank you.
NOTE:  After submitting this form, we will call or email you to confirm your reservation for the CERT class.  If you do not receive confirmation that you are registered for the class, please send email to jwenner@gloucesterva.info or call 804-693-1391.
 Select one of the following:

I would like to register for the November C.E.R.T. class.

I would be interested in additional information on the C.E.R.T. program.
 

Contact Information

Today's Date              

First Name

 *
Last Name *
Mailing Address *
Physical Address
(if different from Mailing Address)
City/State/Zip *  *  *
Nearest cross street to your home address
Phone Number (Day)
Phone Number (Day)
Email at which you want to receive CERT information
   

 

* Required information

Back to Emergency Services
 Revised: May 09, 2008