CA CERT Contact List Survey

Contact Information Update

The purpose of this survey is to update the contact list for CERT Programs in CA. Please complete this survey to ensure that you receive pertinent information regarding the CERT program in California. This survey should be completed by either the CERT Program Manager or the CERT Sponsoring Agency Point of Contact. Please foward this survey to other CERT Programs in your network to help us get as much information as possible. The link is: https://www.surveymonkey.com/r/CACERTContactList

1.Please enter the contact information for the CERT Program and Program Manager

Name of CERT Program

CERT Program Manager First Name

CERT Program Manager Last Name

CERT Program Address Line 1

CERT Program Address Line 2

CERT Program City/Town

CERT Program County

CERT Program ZIP/Postal Code

CERT Program Manager Email Address

CERT Program Manager Phone Number

2.Please enter the contact information for the CERT program sponsoring agency main point of contact (POC)

Name of Sponsoring Agency

Sponsoring Agency POC first name

Sponsoring Agency POC last name

Sponsoring Agency Address Line 1

Sponsoring Agency Address Line 2

Sponsoring Agency City/Town

Sponsoring Agency County

Sponsoring Agency ZIP/Postal Code

Sponsoring Agency POC Email Address

Sponsoring Agency POC Phone Number

3.If you have additional people in your CERT program that you would like to be included on relevant CERT emails please enter their information below

First Name

Last Name

Role with CERT Program (i.e. Additional Staff at Program or Sponsoring Agency, Instructor, Volunteer with Leadership role)

Email Address

Phone Number

4.If you have additional people in your CERT program that you would like to be included on relevant CERT emails please enter their information below

First Name

Last Name

Role with CERT Program (i.e. Additional Staff at Program or Sponsoring Agency, Instructor, Volunteer with Leadership role)

Email Address

Phone Number

5.If you have additional people in your CERT program that you would like to be included on relevant CERT emails please enter their information below

First Name

Last Name

Role with CERT Program (i.e. Additional Staff at Program or Sponsoring Agency, Instructor, Volunteer with Leadership role)

Email Address

Phone Number

Current Progress,

0 of 5 answered