Membership Please Fill out the Below Form in Order to Submit Your Application to become a Member of CERT Illinois Name * Name First First Last Last Phone * Email * Which Jurisdiction do you Belong to? Skills/ Licenses / Certifications that would help CERT To meet the requirements to become a voting member an applicant must be 18 years old and meet one of the following (per IL CERT Assoc. bylaws 9.2.2.1.). Please answer all that are applicable: Name of CERT Team Location of Team Team Leader and/or Contact Name Phone of Leader Email of Leader Website or Facebook address for team (if available) Have You Successfully Completed the CERT Basic Training Program? Did You Complete the CERT Basic Training? Select OneYesNoDoes Not Apply Date of Class Location of Class Do you Currently Belong to a Emergency Management Organization? Organization Name Email Address Contact Person Phone Number If you are human, leave this field blank. Submit
