20012(c) Copy Right CERC and ERCC and ONA

1. CERTIFIED EMERGENCY RESPONSE CHAPLAINS
I.D. CARD APPLICATION/RENEWAL
(Please Print Clearly)
Name:_________________________________________________________________________________
(Last) (First) (M.I.) Street
Address:__________________________________________________________________________
City:_______________________________________________ State:________ Zip:________________
E-mail Address:__________________________________________________________________________
Phone: (_______)________________________________ CERC & ERCC
HQ USE ONLY
Date of Birth:____________________________________
(YYYY) (MM) (DD)
Hair Color:___________________ Height:___________
Eye Color:___________________ Weight:___________
Signature:______________________________________ Date:_______________________________
Submission Option (1): Print this form. Fill in all information. Mail completed and signed form, 2 passport photo's
to (ERCC) to:
Chaplain (LTG) John D. Butler / ERCC/CERC
P.O. Box 3332
Kinston, NC. 28502-3332
Submission Option (2): Print form. Fill in all information. PDF or scan completed and signed form, and email
form and photo (JPEG format) to chaplain_andrew@yahoo.com.
Photo Option (1): Obtain passport photos from the Post Office, Walgreens, UPS, Wal-Mart or other commercial
vendor. Cost is approximately $9.00 for 2 photos. Mail 1 photo with completed and signed form to the address
above.
Photo Option (2): Provide a JPEG photo via email. If you choose this option you MUST strictly adhere to the
following guidelines:
 Take the photo against a plain white or off-white background
 Photo must be full face, front view from top of head to just below the shoulders
 Face in photo should have a natural expression; eyes open, mouth closed, not smiling
 Wear a light colored (white preferred) button-up dress shirt/blouse with top button open
 No clergy attire, uniforms, sunglasses, hats or scarves permitted