CERT REGISTRATION

Use this form to register.

NOTICE: Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to the City of Miami Beach.

* Required Field
*Name:
*Address:
*Home Phone:
Work Phone:
Fax:
E-mail:
Occupation:
Homeowner's Association / Affiliation / Organization:
List your Community Activities:
Briefly explain why you wish to enroll in CERT:
Gender:	Male Female Not Selected
Ethnicity:	White Black or African American American Indian, Alaska Native Asian Native Hawaiian, Other Pacific Islander Hispanic or Latino Other Not Selected
Ethnicity Other:
Education Level:	High School Some College College Degree Bachelor's Degree Master's Degree PhD Other None Selected
Education Other:

For additional information, please contact the City Manager's office at 305.673.7010