TXCDR AlertMedia EnrollmentComplete this form to apply for a TXCDR AlertMedia account. Primary Contact Information Name * First Name Last Name Email * The primary email we should use to contact you. Mobile Phone * The primary mobile phone we should us to contact you (voice and text). (###) ### #### Additional Contact Information. Optional, but the more we have the easier it will be to contact you. Home Address Not required but helpful to locate you if there is a disaster Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile Phone # 2 An alternate mobile phone we can use to try to reach you. (###) ### #### Mobile Phone #3 A second alternate mobile phone we can use to try to reach you. (###) ### #### Home Phone (landline) A home phone we can use to try to reach you for voice communication/messages. (###) ### #### Office Phone (landline, direct/switchboard) An office phone we can use to try to reach you. (###) ### #### Office Phone Post Dial The post-dial instructions if you entered a switchboard number (###) ### #### Email # 2 An alternate email address we can use to try to reach you. Email #3 An alternate email address we can use to try to reach you. About Your Congregation or Organization Congregation or Organization * Title / Role in Organization Organization's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Notes Network or Coalition my Organization responds with. 4B Disaster Response Network (Bay Area and Galveston) Mosaic in Action (Brazoria County) Katy Responds HOPE Disaster Recovery SHUR (Southwest Houston United Responds)) The Restoration Team Other TXCDR Role TXCDR Role * Disaster Readiness Coordinator (DRC) Assistant Disaster Readiness Coordinator (ADRC) Other Thank you for applying for a TXCDR AlertMedia License.
