Form FF 75-5a ( automat FF 75-5a ( automat General Admissions Application - Short Form

U.S. DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT

O.M.B. No. 1660-0007
Expires February 28, 2007

See Reverse for
Privacy Act Statement

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

Yes

3. U. S. CITIZEN

Male

No

If No, City and Country of Birth:

4a. ETHNICITY

4b. RACE (Please chaek all that apply)

1.

HISPANIC or LATINO

1.

AMERICAN INDIAN or ALASKA NATIVE

2.

ASIAN 3.

2.

NOT HISPANIC or LATINO

4.

WHITE

5.

NATIVE HAWAIIAN or PACIFIC ISLANDER

5. PLEASE PRINT YOUR NAME (Last, First, Middle, Suffix)

BLACK or AFRICAN AMERICAN

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. EMAIL ADDRESS
12a. ENTER COURSE CODE AND TITLE

12b. COURSE LOCATION

12c. COURSE DATE

13. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL CONSIDERATION DURING
YES
(If yes, indicate & describe any special considerations required on a separate sheet)
YOUR ATTENDANCE IN TRAINING? NO
SECTION I I - EMPLOYMENT INFORMATION
14a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED
14b. NFIRS#
(NFA ONLY)

16b. ORGANIZATION

16. CHECK THE BOX(S) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
16a. JURISDICTION
4.

1.

STATEWIDE

2.

COUNTY GOVERNMENT 5.

3.

CITY/TOWN/VILLAGE

6.

15. CURRENT POSITION AND NUMBER
OF YEARS IN POSITION

16c. CURRENT STATUS

SPECIALDISTRICT/TOWNSHIP/
7.
TRIBAL NATION
FEDERAL/MILITARY (non-DHS)
8.

1.

ALL CAREER

1.

PAID FULL TIME

FOREIGN

2.

ALL VOLUNTEER

2.

PAID PART TIME

DHS/FEMA

3.

COMBINATION

3.

VOLUNTEER

INDUSTRY/BUSINESS

NDER/IMA

4.

DISASTER RESERVIST

9.

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 National Emergency Training Center (NETC), the Mt. Weather Emergency Operations Center (MWEOC), and the Noble Training Center
(NTC) 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 NTC. 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.
18a. SIGNATURE OF APPLICANT

18b. DATE

19. APPROVAL BY 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)
20b. SIGNATURE AND DATE (FEMA Regional Office)

21. SUBMIT APPLICATION TO APPROPRIATE SPONSOR

FEMA Form 75-5A, AUG 04

REPLACES ALL PREVIOUS EDITIONS

22b. 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 and submitting the form. Send comments regarding the
accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, U. S. Department of Homeland
Security, Federal Emergency Management Agency 500 C Street, SW, Washington, DC 20472 (Paperwork Reduction Project 1660-0007). Your response
is voluntary, and you are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right
corner of this form. NOTE: Do not send your completed form to this address. Please return it to the appropriate address shown in block 24.