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2. First Name*
3. Middle Name
4. Last Name*
6. Date of Birth (mm/dd/yy)*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Alternate Phone Number
17. Email Address*
19. Have you ever been convicted of a crime (felony/misdemeanor)?*

    1. Yes
    2. No
21. Have you ever been charged with a crime?*

    1. Yes
    2. No
23. Do you have any training or certifications which would benefit your service?*
25. Are you retired or current...*

    1. Military
    2. Law Enforcement
    3. EMS
    4. Fire
    5. Medical Field
    6. CPR/First Aid
    7. Other beneficial career

    Select all that apply.

27. Please explain why service with the Waterford Citizens Emergency Response Team interests you*
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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

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