General Admissions Application
DEPARTMENT OF HOMELAND SECURITY
O.M.B. No. 1660-0100
FEDERAL EMERGENCY MANAGEMENT AGENCY
See Reverse for
Expires May 31, 2010
GENERAL ADMISSIONS APPLICATION
Privacy Act Statement
SECTION I - GENERAL INFORMATION
1. U.S. Citizen
YES
NO
If No, City and Country of Birth:
2. NAME (Last, First, Middle Initial, Suffix)
3. SOCIAL SECURITY NUMBER
4. HOME ADDRESS (Street, avenue, road no./city or town, state, and zip code)
5. WORK PHONE NO. ( )
6. HOME PHONE NO. ( )
7. FAX NO.
( )
8. E-MAIL ADDRESS:
9a. ENTER COURSE CODE AND TITLE: (If you wish to apply for more than one course, 9b. COURSE LOCATION
9c. DATES REQUESTED (Please give three choices)
please attach a sheet of paper to this application)
10. COMPLETE THE ITEMS BELOW REGARDING THE PREREQUISITES OF THE COURSE FOR WHICH YOU ARE APPLYING
INSTITUTION
DEGREE/CERTIFICATE
DATE EARNED
COURSE/FIELD OF STUDY
11. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL ASSISTANCE DURING YOUR ATTENDANCE IN TRAINING?
NO
YES
(If yes, describe & indicate any special assistance required on a separate sheet)
SECTION II - EMPLOYMENT INFORMATION AND AUTHORIZATION
12a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED
12b. NFIRS #
13. CURRENT POSITION AND NUMBER OF YEARS
(NFA STUDENTS
IN POSITION
ONLY)
14. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
14 a. JURISDICTION
SPECIAL DISTRICT/TOWNSHIP/
14 b. ORGANIZATION
15. CURRENT STATUS
1.
STATEWIDE
4.
TRIBAL NATION
7.
FOREIGN
1.
ALL CAREER
1.
PAID FULL TIME
2.
COUNTY GOVERNMENT
5.
FEDERAL/MILITARY (non-DHS)
8.
DHS/FEMA
PAID PART TIME
2.
ALL VOLUNTEER
2.
3.
CITY/TOWN/VILLAGE
6.
INDUSTRY/BUSINESS
9.
NDER/IMA
3.
VOLUNTEER
3.
COMBINATION
4.
DISASTER RESERVIST
16. Briefly describe your activities/responsibilities as they relate to the course for which you are applying and identify how you will use the information obtained from the course. Attach an
organizational chart for the organization being represented and indicate your position. If you need more space, please attach a sheet to this application.
17. CHECK ONE BOX IN EACH COLUMN THAT BEST DESCRIBES YOUR PRESENT PRIMARY RESPONSIBILITY AND TYPE OF EXPERIENCE AS IT RELATES TO THE COURSE FOR
WHICH YOU ARE APPLYING. ALSO ENTER THE NUMBER OF YEARS OF EXPERIENCE.
17a. PRIMARY RESPONSIBILITY
17b. TYPE OF EXPERIENCE
1.
1.
17c. NUMBER OF YEARS OF EXPERIENCE
MANAGEMENT
INCIDENT COMMAND
2.
2.
TRAINING/EDUCATION
ADMINISTRATION/STAFF SUPPORT
17d. SIZE OF DEPARTMENT
3.
SCIENTIFIC/ENGINEERING
3.
SUPERVISION
4.
INVESTIGATION
4.
BUDGET/PLANNING
17e. BUSINESS TYPE
5.
FIRE PREVENTION
5.
PROGRAM DEVELOPMENT/DELIVERY
1.
GOVERNMENT
6.
FIRE SUPPRESSION
6.
COORDINATION/LIAISON
2.
EDUCATION
7.
PROGRAM/ACTIVITY
7.
PUBLIC EDUCATION
3.
FIRE SERVICE
8.
HEALTH
8.
CODE DEVELOPMENT
4.
LAW ENFORCEMENT
9.
PUBLIC WORKS
9.
CODE ENFORCEMENT/INSPECTION
VOLUNTEER AGENCY
10.
DISASTER RESPONSE/RECOVERY
10.
SUPPORT SERVICES
5.
EMERGENCY MANAGEMENT
11.
EMERGENCY MEDICAL SERVICE
11.
RESEARCH AND DEVELOPMENT
6.
12.
HAZARD MITIGATION
12.
ARSON
7.
HEALTH CARE
13.
EMERGENCY PREPAREDNESS
13.
LAW ENFORCEMENT
8.
PUBLIC WORKS
14.
OTHER (Specify)
14.
DESIGN AND PLANNING
15.
OTHER (Specify)
18. DATE OF BIRTH
19. GENDER
20a. ETHNICITY
Male
Female
HISPANIC or LATINO
NOT HISPANIC or LATINO
20b. RACE (Please check all that apply)
1.
AMERICAN INDIAN or ALASKA NATIVE 2.
ASIAN 3.
BLACK or AFRICAN AMERICAN
4.
WHITE
5.
NATIVE HAWAIIAN or PACIFIC ISLANDER
FEMA Form 75-5, JUL 07
PREVIOUS EDITION OBSOLETE
SECTION III - ENDORSEMENT AND CERTIFICATION
21a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (18 U.S.C. 1001).
21b. I hereby authorize the release of any and all information concerning my enrollment in this course to the chief officer in charge, or designee, of my organization. All
requests for information shall be in writing from said chief or designee.
21c. Further, I understand that the National Emergency Training Center (NETC), the Mt. Weather Emergency Operations Center (MWEOC), and the Noble Training Facility
(NTF) are not authorized to provide medical or health insurance for students. I maintain appropriate insurance on an individual basis.
21d. I agree to abide by the rules, policies, and regulations of NETC, MWEOC, and NTF. Failure to do so will result in denial of the student stipend, expulsion from the
course, and possible barring from future National Fire Academy (NFA) and Emergency Management Institute (EMI) courses.
SIGNATURE OF APPLICANT
DATE
22. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION
"By signing this application, I certify that my organization does not discriminate on the basis of age, sex, race, color, religious belief, national origin, economic status, or disability in providing
educational opportunities for its employees."
22a. SIGNATURE
22b. PRINTED NAME AND TITLE
23. ADDITIONAL ENDORSEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE:
23a. SIGNATURE AND DATE (State Office)
23b. SIGNATURE AND DATE (FEMA Regional Office)
24a. FOR NFA REGIONAL DELIVERY COURSES AND COURSES
24b. FOR EMI COURSES DELIVERED AT NETC, MWEOC, OR NTF
DELIVERED AT EMMITSBURG, MD. SUBMIT APPLICATION TO:
SUBMIT APPLICATION THROUGH THE APPROPRIATE STATE
EMERGENCY MANAGEMENT COORDINATOR OR FEMA REGIONAL
TRAINING MANAGER TO NETC.
NATIONAL EMERGENCY TRAINING CENTER
OFFICE OF ADMISSIONS, BLDG. I-216
16825 SOUTH SETON AVENUE
24c. FOR FIELD PROGRAM COURSES, SUBMIT APPLICATION TO
EMMITSBURG, MD. 21727
APPROPRIATE SPONSOR.
25. DISPOSITION
SIGNATURE OF REVIEWER
DATE
ACCEPTED
REJECTED
EQUAL OPPORTUNITY STATEMENT
NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, sex, race, color, religious belief, national origin, or disability in their admissions
and student-related procedures. Both schools make every effort to ensure equitable representation of minorities and women in their student bodies. Qualified minority and
women candidates are encouraged to apply for all courses.
PRIVACY ACT STATEMENT
GENERAL - This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), Title 5 United States Code (U.S.C.) Section 552a, for individuals applying for
admission to NFA or EMI.
AUTHORITY - Federal Fire Prevention and Control Act of 1974, as amended, Title 15 U.S.C., Sections 2201 et. seq.; Robert T. Stafford Disaster Relief and Emergency
Assistance Act, as amended, Title 42 U.S.C., Sections 5121 et. seq.; Title 44 U.S.C., Section 3101; Executive Orders 12127, 12148, and 9397; Title VI of the Civil Rights Act
of 1964; and Section 504 of the Rehabilitation Act of 1973.
PURPOSES - To determine eligibility for participation in NFA and EMI courses. Information such as age, sex, and ancestral heritage are used for statistical purposes only.
USES - Information may be released to: 1) FEMA staff to analyze application and enrollment patterns for specific courses, and to respond to student inquiries; 2) a physician
to provide medical assistance to students who become ill or are injured during courses; 3) Members of the Board of Visitors for the purpose of evaluating programmatic
statistics; 4) sponsoring States, local officials, or State agencies to update/evaluate statistics of NFA and EMI participants; 5) Members of Congress seeking first party
information; and 6) Agency training program contractors and computer centers performing administrative functions.
EFFECTS OF NONDISCLOSURE - Personal information is provided on a volunteer basis. Failure to provide information on this form, however, may result in a delay in
processing your application and/or certifying completion of the course.
INFORMATION REGARDING DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER UNDER PL 93-579, SECTION 7(b) - E.O. 9397 authorizes the collection of the
SSN. The SSN is necessary because of the large number of individuals who have identical names and birthdates and whose identities can only be distinguished by the SSN.
The SSN is used for recordkeeping purposes, i.e., to ensure that your academic record is maintained accurately. Disclosure of the SSN is voluntary. However, if you do not
provide your SSN, another number will be substituted, which will delay processing your application or course certificate.
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 9 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing
data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of
information unless it displays a vaild OMB control number. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to:
Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork
Reduction Project (1660-0100). NOTE: Do not send your completed form to this address.
