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2. Name (First, Last)*
4. Address1*
6. Address2
8. City*
9. State*
10. Zip*
12. Community Affiliation
14. Email*
16. Phone Number*
18. Next Available CERT Class*

    1. Currently there is no upcoming class scheduled. Select this box to be added to the waiting list. You will be updated as soon as a class is scheduled.

    All dates must be attended to complete the training.
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20. 1. Receive an email copy of this form.
21. Email address

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22. Submit

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