CERT Application

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Please correct the fields below:

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Name
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Name
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Home Address
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Home Address
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Other Contact Information
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Other Contact Information
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 Date and Place of Birth
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Date and Place of Birth
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Sex
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Sex
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Race
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Race
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Driver's License Information
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Driver's License Information
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Has your Driver's License ever been suspended?

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Has your Driver's License ever been suspended?
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If your Driver's Licenses has been suspended in the past please state when and why?

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Are you a resident of Collier County?

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Are you a resident of Collier County?
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If other residency, where?

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Are you a U.S. Citizen?

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Are you a U.S. Citizen?
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Have you ever been convicted of a felony crime, please explain.
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List all law enforcement experience.


EMPLOYMENT INFORMATION:
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Current Employer or Most Recent

Current Employer or Most Recent

GENERAL INFORMATION:

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Have you or your relatives ever worked for the Collier County Sheriff's Office?

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Have you or your relatives ever worked for the Collier County Sheriff's Office?
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If yes, please tell us who?

If yes, please tell us who?
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CERTIFICATION
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Liability Waiver Form

To the best of my knowledge, I am in good physical condition and fully able to participate in this course. I am fully aware of the risks and hazards connected with the participation in CERT Training, including physical injury or even death, and herby elect to voluntarily participate in said event, knowing that the associated physical activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OR LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH, that may be sustained by me, or loss or damage to property owned by me, as a result of participation in this course. I further certify that I am at least 18 years of age. If under 18, my parent/guardian is the below signed.

I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, The Collier County Sheriff’s Office, their officers, servants, agents, and employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, while participating in physical activity, or while on or upon the premises where the event is being conducted.

It is my expressed intent that this release and hold harmless agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a RELEASE, WAIVE, DISCHARGE, and CONVENTION TO SUE the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be constructed in accordance with the laws of the State of Florida.

In signing this release, I acknowledge and represent that I HAVE READ THE FOREGOING Waiver of Liability and Hold Harmless Agreement, UNDERSTAND IT AND SIGN IT VOLUNTARILY as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreements have been made; and I EXECUTE THIS RELEASE FOR FULL, ADEQUATE AND COMPLETE CONSIDERATION FULLY INTENDING TO BE BOUND BY SAME.

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