BOCH CERT New Member Application

BOCH Community Emergency Response Team

Thank You for your interest in joining our team! Please fill out this form and once submitted, the team will get back to you on your next steps.

Personal References

Please Provide Three (3) Personal References. (Not Previous Employers or Relatives)


Information For CORI Background Check

The Next sections will contain questions regarding any background checks we perform for volunteers.


PLEASE NOTE:

The following exceptions which should not be reported:

An arrest not leading to a conviction.

A first conviction for the following misdemeanors: drunkenness, simple assault,
speeding, minor traffic infractions, affray, or disturbing the peace.

Any conviction for a misdemeanor more than five years old.

If Yes, describe in full in the following section.


Individual Authorization for CORI Check

Please Read the Following:

I consent to having a background check into my fitness to be a Citizen Corps volunteer.

This will include a criminal background check. By signing this authorization form, I acknowledge that employers, references, and other pertinent agencies and individuals may be contacted as to my fitness for this purpose. I authorize those parties contacted pursuant to this investigation to release any pertinent information they may have concerning me to the Brewster-Orleans-Chatham-Harwich (BOCH) Regional CERT Council and any volunteer agency or government agency involved with Citizen Corps Emergency Preparedness, Response, and Recovery Operations, to also include any
emergency dispensing sites.

I waive and release any right or claim that might arise, in the course of and/or resulting from this investigation. I agree to indemnify and hold harmless, including reasonable attorney fees, the BOCH Regional CERT Council, the towns of Brewster, Orleans, Chatham, and Harwich, their elected officials as well as their officers, employees, agents and assigns.

This waiver and release also covers and indemnifies any present or past employer, their officers, agents, principals, employees, as well as any person or party who responds to my background investigation.

A Photocopy of this authorization and release will be valid as an original.

By Submitting this form to BOCH CERT you authorize the process to begin and promise to make available within 30 days a hard copy with signatures at first meeting, an emailed scanned copy, or by mailing to our offices at:


BOCH Regional CERT
c/o Chatham Fire Department
135 Depot Road
Chatham, MA 02633


Parental Authorization for Volunteers under the age of 18

All members under the age of 18 must have a parental signiture on all applications

If you are the parent providing authorization, please provide your name and phone number below.


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