CERT Service Request Form

Required fields are marked with an asterisk (*).

1. Date Submitted: *
2. Date of Event: *
3. Purpose or Event Type: *
4. Services Required: *

   Fire Rehab
   Parade Route Traffic Control
   5k/10k/Race Traffic Control
   Traffic Control, Parking Assistance, or other Crowd Control
   Community Events (Pancake Breakfast, Fireworks, Fundraisers)
   Moulage for Exercises and Drills
   Information Booth
   Other - Please Specify

   Please select at least one service.
5. Other Specific Request:
6. Location:
7. Name of Requesting Organization: *
8. Contact Person: *
9. Contact Email: *
10. Contact Phone Number: *
11. Describe Work on Project:
12. Special Instructions or Requests:
13. Will you be giving a donation to the CERT Team for the use of their services? A 501c3 Nonprofit number is available for tax purposes: * Please Select Yes No

Thank you for considering the Des Moines County Community Emergency Response Team to help with your event!

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