CFA Application

							Area   ____________                                                          Approved ____________
RD     ___________                                                           Class Date ___________
Rec’d Date_________


               COSTA MESA FIRE DEPARTMENT
    COMMUNITY EMERGENCY RESPONSE TEAM/CITIZENS FIRE ACADEMY
                        APPLICATION
NAME___________________________________ BIRTH DATE _______________________

ADDRESS____________________________________________________________________
                                                      (City)                           (Zip)

WORK ADDRESS ____________________________________________________________________
                                           (City)                         (Zip)

TELEPHONE NUMBERS _____________________________ / _______________________________
                             (Home)                            (Work)

EMAIL: ____________________________________________________________________________

DRIVERS LICENSE# _____________________ STATE __________ EXP. DATE ________________

OCCUPATION _______________________________________________________________________

EMERGENCY CONTACT: _____________________________________________________________

PHONE: _____________________________ ALTERNATE PHONE: ___________________________

Which program (s) are you interested in?   CERT __________        Citizens Fire Academy ________

I consent to a criminal records check and/or fingerprints (taken by CMPD) if required for eligibility to
participate in CERT activities or the Costa Mesa Citizens Fire Academy. I agree to abide by all rules
and regulations.

Applicant’s Signature _______________________________________ Date ____________________

HOW DID YOU HEAR ABOUT OUR CERT PROGRAM OR CITIZENS ACADEMY?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

MAIL FAX OR DELIVER APPLICATION TO:
CERT/Citizens Fire Academy ~ Attn: Brenda Emrick - FIRE PREVENTION BUREAU
Fax: 714.327.7408   Mail: 2803 Royal Palm Avenue Costa Mesa, CA 92626