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2. First and Last Name*
4. Email Address*
6. Phone Number*
8. Home Address (e.g. 1210 Golden Gate Dr, Papillion, NE 68046)*
10. County of Residence*
12. Scheduling (check all boxes that apply)*

    1. I'm interested in attending a class that's held over one weekend.
    2. I'm interested in attending a class that's primarily held during weeknights over the course of several weeks.
14. By submitting this form you grant us permission to contact you about the CERT program.
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15. Submit

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