Technical Assistance Registration

Technical Assistance Registration

Note: entry is required where field is bold

First Name:

Last Name:

Address:

City:

State:

ZIP Code:

Birth Year:

Phone:

Additional Phone:

Email:

Occupation:

Employer:

Start Date:

Please enter date in format MM/DD/YYYY

Duration:

Type of Assistance: Volunteer
Salary Only
Expenses Only
Salary and Expenses

Is this offer for voluntary service, or do you expect to be paid. If so, are you expecting to be paid a fee or salary for service, expenses, or both.

Describe education (degrees) and language capabilities:

Do you have disaster response experience? Yes
No

If yes, can you provide details?

If you have previous disaster assistance experience, please give sufficient details for follow-up.

Service/Skills:

Give a good account of your background and how you expect to contribute in a disaster response.

Do you currently hold a valid passport? Yes
No

In order to be considered for overseas assistance, it is necessary to have a valid passport. You may not have the appropriate visa(s), but those are more readily obtained.

This information can be given to governmental and non-governmental organizations: Yes
No

The information you have provided is accessed by agencies (governmental and non-governmental) working in the disaster location. If you choose to not make your information available to agencies, you will not be considered for providing response assistance through the CIDI and your information will not be included in the database

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Center for International Disaster Information