CHESTER COUNTY
DEPARTMENT OF EMERGENCY SERVICES
2010 CERT/VOAD REGISTRATION FORM
TRAINING DATES: (Please check the session you want to attend)
_____ Thursday, March 11
Saturday, March 13
_____ Thursday, May 13
Saturday, May 15
_____ Thursday, August 12
Saturday, August 14
_____ Thursday, November 4
Saturday, November 6
Class size is limited, please register early !
Note: The Chester County Department of Emergency Services does not send out registration confirmations for courses. Participants will only be notified of cancellations. Thank you.
Please Print Clearly! *Required Fields
Name* ___________________________________________________________
Social Security* ___________________________________________________________
Home Addresss* ___________________________________________________________
City/State/Zip* ___________________________________________________________
Organization ____________________________________________________________
Home Tel #* ____________________________________________________________
Work Tel #* ____________________________________________________________
E-mail Addresss ____________________________________________________________
Return the response by one of the following methods:
1. Fax: 610-344-5050
3. Mail: Dept. of Emergency Services (Attn:Rosemary Geldof)
601 Westtown Road, Suite 012
P.O. Box 2747
West Chester, PA 19380-0900
