First Name: Last Name:
Previous EOC Volunteer:
Current CERT (Community Emergency Response Team) Member:
Which CERT?
DOB:  (mm/dd/yyyy) SSN:  (###-##-####)

Cell Phone: Home Phone:

Emergency Contact Name:
Emergency Contact Relation:
Emergency Contact Phone:

How did you hear about Lee County Emergency Management's Volunteer program?

What Volunteer area interests you? (Training will be provided for all areas.)
(potentially receive college credits for volunteer hours)
(must be a licensed amateur radio operator or interested in becoming licensed)
(choose all that apply)

I understand pursuant to the requirements of the Fair Credit Reporting Act, a consumer report may be made in connection with my volunteer application. FEDERAL LAW DEEMS CRIMINAL BACKGROUND CHECK AS A "CONSUMER REPORT". If I am denied the opportunity to volunteer, either wholly or partly, because of information contained in a consumer report, a disclosure will be made to me of the name and address of the consumer-reporting agency making such a report. I will also receive a copy of the report and a statement of my consumer rights. I have read the above notice and understand what it means. I hereby authorize the procurement of a consumer report at the time of my application, or at any time during my volunteer service with Lee County Emergency Management. I understand that any falsification, omission, misrepresentation or false statement on this application shall be sufficient cause for rejection of my application or dismissal from any volunteer activities with Lee County Emergency Management and/or its affiliated programs. Checking the box next to this disclosure shall substitute for and have the same legal effect as an original signature. Note: The term “Consumer Report” means a report by a consumer reporting agency bearing on a consumer’s credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used or collected in whole or in part for the purpose of serving as a factor in establishing the consumer’s eligibility for: (a) credit or insurance to be used primarily for personal, family, or household purposes; (b) employment   purposes; or (c) any other purpose authorized by 15 U.S.C § 1681(6).