General Admissions Application Short Form

DEPARTMENT OF HOMELAND SECURITY
O.M.B. No. 1660-0100
Expires May 31, 2010
See Reverse for
Privacy Act Statement
FEDERAL EMERGENCY MANAGEMENT AGENCY
GENERAL ADMISSIONS APPLICATION SHORT FORM
USE THIS FORM ONLY IF APPLYING FOR NFA OFF CAMPUS COURSES (EXCLUDING REGIONAL DELIVERIES)
SECTION I - GENERAL INFORMATION
1. DATE OF BIRTH (Mo, Day, Yr.)
2. SEX
FEMALE
4a. ETHNICITY
HISPANIC or LATINO
1.
2.
MALE
3. U.S. CITIZEN
4b. RACE (Please check all that apply)
AMERICAN INDIAN or ALASKA NATIVE
1.
NOT HISPANIC or LATINO
4.
WHITE
YES
NO
2.
ASIAN
5.
NATIVE HAWAIIAN or PACIFIC ISLANDER
If No, City and Country of Birth:
BLACK or AFRICAN AMERICAN
3.
5. PLEASE PRINT YOUR NAME (Last, First, Middle, Suffix)
6. SOCIAL SECURITY NO.
7. MAILING ADDRESS (Street, avenue, road no./city or town, and zip code)
8. WORK PHONE NO. (
)
9. HOME PHONE NO. (
)
10. FAX NO. (
)
11. E-MAIL ADDRESS
12a. ENTER COURSE CODE AND TITLE
12b. COURSE LOCATION
12c. DATE
13. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING YOUR ATTENDANCE IN TRAINING?
NO
YES
(If yes, indicate & describe any special considerations required on a seperate sheet)
SECTION II - EMPLOYMENT INFORMATION
14a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED
14b. NFIRS #
(NFA ONLY)
16. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
16a. JURISDICTION
STATEWIDE
1.
4.
SPECIAL DISTRICT/TOWNSHIP/
TRIBAL NATION
2.
COUNTY GOVERNMENT
5.
FEDERAL/MILITARY (non-DHS)
3.
CITY/TOWN/VILLAGE
6.
INDUSTRY/BUSINESS
15. CURRENT POSITION AND NUMBER OF YEARS IN
POSITION
16b. ORGANIZATION
16c. CURRENT STATUS
FOREIGN
1.
ALL CAREER
1.
PAID FULL TIME
8.
DHS/FEMA
2.
ALL VOLUNTEER
2.
PAID PART TIME
9.
NDER/IMA
3.
COMBINATION
3.
VOLUNTEER
4.
DISASTER RESERVIST
7.
SECTION III - ENDORSEMENT AND CERTIFICATION
17a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (U.S.C. 1001).
17b. 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 officer or designee.
17c. 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.
17d. 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.
18b. DATE
18a. SIGNATURE OF APPLICANT
19. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION (NOT REQUIRED FOR SELF STUDY PROGRAMS)
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.
19a. SIGNATURE
19b. PRINTED NAME AND TITLE
19c. DATE
20. ADDITIONAL ENDORSEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE (NOT REQUIRED FOR SELF STUDY PROGRAMS)
20a. SIGNATURE AND DATE (State Office)
20a. SIGNATURE AND DATE (FEMA Regional Office)
21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR
FEMA Form 75-5A, JUL 07
PREVIOUS EDITION OBSOLETE
20b. SIGNATURE OF REVIEWER
22a. DISPOSITION
ACCEPTED
22c. DATE
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 record-keeping 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 of
your application or course certificate.
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 6 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 a vaild OMB control number appears
in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management,
Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1670-0100). NOTE: Do not send your
completed form to the above address.