Membership Application

Step 1 of 5: About you

Step 1 of 5

About you

Tell us who you are and how to reach you.

First name

Last name

Email address

Date of birthMembers must be 18 or older.

Social Security number OptionalOptional now, but needed before you join the team: it is for your background check. Encrypted as soon as you send the application, and never emailed.

Where you live

Street address

Town or city

State

ZIP code

How long have you lived here?

Phone and work

Cell phone

Home phone

Give at least one phone number, cell or home.

Current employer Optional

Employer's address Optional

Step 2 of 5: Driver's license

Step 2 of 5

Driver's license

Members need a valid Connecticut driver's license with no moving violations in the past five years. We confirm this with a license history check.

License numberConnecticut: nine digits.

State

License class

License expiresAs printed on your license.

Endorsements Optional

Restrictions Optional

Do you have any motor vehicle violations?

Yes No

When?The month and year. More than one? Give the latest here and list them all under Type of violation.

Type of violation

A copy of your driver's license

Add a photo or scan of your licenseA PDF or a photo (JPG, PNG or WebP), up to 10 MBChoose file

Step 3 of 5: Emergency contact

Step 3 of 5

Emergency contact

Who should we call if something happens to you while you're with the team?

Name

Relationship to you

Phone

They live at my address

Their address

Step 4 of 5: Certifications

Step 4 of 5

Certifications

Tell us about any certifications you already hold. None yet? That's fine: CERT training covers what you need.

Current certifications

EMSMRT, EMT and similarFire serviceFF1, FF2 and similarParamedicA current paramedic licenseOtherCPR, first aid, ham radio and more

Which other certification?

Copies of your certificates Optional

Add your EMS certificatesPDFs or photos (JPG, PNG or WebP), up to 10 MB each. Up to 5 files.Choose files

Add your fire service certificatesPDFs or photos (JPG, PNG or WebP), up to 10 MB each. Up to 5 files.Choose files

Add your paramedic licensePDFs or photos (JPG, PNG or WebP), up to 10 MB each. Up to 5 files.Choose files

Add your other certificatesPDFs or photos (JPG, PNG or WebP), up to 10 MB each. Up to 5 files.Choose files

Incident Command System certificates

Every member needs these four free online courses from FEMA. Not done yet? That's okay. We'll tell you how to send them in.

ICS 100Introduction to the Incident Command System

Take it free (FEMA, opens a new tab)

Add the certificateA PDF or a photo (JPG, PNG or WebP), up to 10 MBChoose file

ICS 200Basic Incident Command System for Initial Response

Take it free (FEMA, opens a new tab)

Add the certificateA PDF or a photo (JPG, PNG or WebP), up to 10 MBChoose file

ICS 700An Introduction to the National Incident Management System

Take it free (FEMA, opens a new tab)

Add the certificateA PDF or a photo (JPG, PNG or WebP), up to 10 MBChoose file

ICS 800National Response Framework, An Introduction

Take it free (FEMA, opens a new tab)

Add the certificateA PDF or a photo (JPG, PNG or WebP), up to 10 MBChoose file

Step 5 of 5: Review and sign

Step 5 of 5

Review and sign

Check your answers, then read and sign the agreement.

Your agreement

I have read and understood all the questions. I attest to the accuracy and completeness of the information provided.I understand that I must complete a three (3) month probationary period.I understand that to maintain my membership as an OEM/CERT volunteer, I must comply with the rules and regulations of CERT/OEM and the standard operating procedures (SOPs) of the Office of Emergency Management.I agree that as part of this application process, I will be subjected to a pre-offer drug screening, criminal background check and motor vehicle background check.I authorize the Office of Emergency Management, the Department of Fire and Emergency Services and/or their agents to verify any statements made on this application at their discretion, and to obtain said verification from any local, state or federal agencies, whether public or private, when necessary.

Signature

Type your full name to signTyping your name is your signature on this application.

About you

Where you live

Phone and work

Driver's license

Emergency contact

Certifications

Current certifications

Incident Command System certificates

Review and sign

Your agreement

Signature