Team Member Contact Information Update

If you have moved, changed your phone number, changed your name or just want to make sure we have your current information, fill out the form below.  Fields marked with an asterisk * are required.  As always, your information is kept strictly confidential and is used only for organization of volunteers in an emergency.  If you are bi-lingual or have another skill we might utilize in an emergency, please list it in the comments section.  Thank you for taking the time to make CERT great! 


Last Name *
First Name *
Middle
Year of Graduation
Address (number and street) *
Apt. #
City, State Zip Code (if other than Newark)
Phone Number *
Cell Number
E-mail Address *
Do you wish to be contacted? *
 Yes
 No
Comments or questions:
 

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