Form FEMA Form 646-0-1 FEMA Form 646-0-1 National Defense Executive Reserve Personal Qualificatio

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

See Privacy Act Statement and
Paperwork Burden Disclosure Notice on
page 2

NATIONAL DEFENSE EXECUTIVE RESERVE
PERSONAL QUALIFICATIONS STATEMENT

1. NAME (last, First, Middle)

RETURN ORGINAL TO: (Sponsoring Agency)

Mr.

Mrs.

Miss

Ms.

OTHER TITLES USED (Gen, Dr., etc.)

3. PREFERED MAILING ADDRESS

2. HOME ADDRESS (City, state and zip code)

HOME
5. ARE YOU A CITIZEN OF THE UNITED
STATES?

4. SSN (Last four Digits)

O.M.B. No. 1660-0001
Expires August 31, 2009

6. BIRTH DATE (Month, day,
year)

BUSINESS
7. BIRTHPLACE

NO

YES
8. HOME TELEPHONE (Including area code)

HOME E-MAIL

FAX

9. BUSINESS TELEPHONE (Including are code)

BUSINESS E-MAIL

FAX

11. Name of College or University

NO

YES

10. HIGH SCHOOL GRADUATE

Dates Attended (mo/yr)
From
To

Major and Other Principal Subjects

Degree Received

Year Received

12. SKILL AREAS (Select Primary and Secondary Skills From Listing on Page 3 of this Form)
12a. PRIMARY

12b. SECONDARY

13. EMPLOYMENT EXPERIENCE (Start with you most recent position and work back at least 5 years. If more space is required, continue on a separate sheet of
paper with your name at the top and give similar information.)
TYPE OF BUSINESS (Select from listing on page 3 of this form)
13a. NAME & ADDRESS OF ESTABLISHMENT (if retired, please indicate)
Number of Emloyees you Number of Employees in you Establishment
Supervise(d)
Less than 500
5000 - 5000
Over 5000
NAME AND TITLE OF YOUR SUPERVISOR

DATES OF EMPLOYMENT
TO

FROM

TITLE OF YOUR POSITION

PRESENT
DESCRIPTION OF WORK (Describe your specific duties)

13a. NAME & ADDRESS OF ESTABLISHMENT (if retired, please indicate)

TYPE OF BUSINESS (Select from listing on page 3 of this form)
Number of Emloyees you Number of Employees in you Establishment
Supervise(d)
Less than 500
5000 - 5000
Over 5000
NAME AND TITLE OF YOUR SUPERVISOR

DATES OF EMPLOYMENT
TO

FROM

TITLE OF YOUR POSITION

PRESENT
DESCRIPTION OF WORK (Describe your specific duties)

FEMA Form 646-0-1,

REPLACES ALL PREVIOUS EDITIONS.

14. LIST BELOW ANY ACTIVITIES AND MEMBERSHIPS (Such as CPA, Bar membership, Professional and Learned Societies, Trade Associations, etc.)

15. PREVIOUS GOVERNMENT EXPERIENCE (Federal, state, or local; also include WOC (Without compensation) positions, but exclude committee memberships)
FROM

TO

AGENCY

16. WOULD YOU SERVE ANYWHERE IN THE UNITED STATES IF CALLED TO ACTIVE DUTY AS AN EXECUTIVE RESERVIST? (If "NO" specify acceptable geographical
area(s) in which you would be willing to serve)
NO
YES
17. DO YOU HAVE ANY OBLIGATION THAT MIGHT INTERFERE WITH AN EXECUTIVE RESERVE CALL-UP? (Such as military, civil defense, elected public office, etc.)
(If yes, specify)
YES

NO

18. APPLICANT'S SIGNATURE (Sign in ink)

19a. POSITION TITLE

DATE
19. SPONSORING AGENCY PROPOSED NDER ASSIGNMENT
19b. GEOGRAPHICAL LOCATION (Specify)
National Office
Region (specify)

19c. BRIEF DESCRIPTION OF DUTIES

20. DATE OF PRECLEARANCE
SECURITY NAME CHECK

21. REQUESTING OFFICIAL (Name and title)

DATE

22. ACTION BY FEMA: RECRUITMENT OF CANDIDATE
OTHER (See attached memo)
APPROVED
DISAPPROVED

23. NDER COORDINATOR

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 30 minutes per response. The burden estimate includes the time for reviewing
instructions and searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You
are not required to respond to this collection of information unless a valid 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 the burden to: Information
Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC
20472, Paperwork Reduction Project (1660-0001). NOTE: Do not send your completed form to this address.
PRIVACY ACT STATEMENT
Under Section 710(e) of the Defense Production Act of 1950, as amended, and Executive Order (E.O.) 12919 Part VI, Section 601, the President
of the United States authorizes the Federal Emergency Management Agency to provide for the establishment and training of a nucleus
executive reserve for employment in executive positions in government during periods of emergency. Sponsoring Federal departments and
agencies are authorized to recruit for National Defense Executive Reservists.
We request your social Security Number (SSN) under authority of E.O. 9397 and your date of birth (DOB) to keep our records straight because
other people may have the same name and birth date. In the event you become a member of the NDER and are activated to serve in an
executive position, your SSN and DOB will be used to complete the forms for Federal employment.
We will use the information to evaluate your qualifications to serve as a reservist, to grant approval of your appointment to other Federal
agencies, to facilitate training and for routine management of the NDER program. in addition, we may use the information to obtain a
background check or complete an investigation for a security clearance, and to publish a directory of NDER members, which would be
available to Federal officials with responsibility for the NDER program.
Completing this form is mandatory for membership in the NDER but furnishing your SSN is voluntary. Failure to provide your SSN, however,
will cause confusion and may prevent us from processing the application, which is needed to qualify you as a member of the NDER.
We may give information from your records to: law enforcement agencies where there may be a violation or potential violation of law; the
National Archives and Records Administration during records management inspections under 44 USC 2904 and 2906; a federal, state, or local
agency if necessary to obtain information relevant to an Agency decision concerning hiring or retention or issuance of a benefit; a member of
Congress or Congressional staff member in response to an inquiry made by you; and to a federal agency, court or party in litigation with a
federal agency when the government is a party to a judicial proceeding or recipient of a subpoena.

SKILL AREAS

(Select appropriate area(s) and enter in items 12a. and 12b. of this form)
ARCHITECTURE & ENVIRONMENTAL DESIGN
Architecture
City Planning

EDUCATION
Training
ENGINEERING
Aeronautical
Architectural
Chemical
Civil
Electrical
Environmental
Industrial
Marine
Mechanical
Mining
HEALTH PROFESSIONS
Doctor
Nurse
Nutrition
Pharmacology
Technician

BIOLOGICAL SCIENCES
Bacteriology
Biology
Botany
BUSINESS
Accounting
Banking & Finance
Hotel & Restaurant Management
Insurance
International Business
Investments & Securities
Labor & Industrial Relations
Management
Marine Transportation
Marketing & Purchasing
Operations Research
Personnel Management
Public Utilities
Real Estate
Transportation

Physics

SCIENCES
Chemistry
Geology
Mathematics
Metallurgy
Meteorology
Psychology

Statistics

SOCIAL SCIENCES
Economics
International Relations

LAW
NATURAL RESOURCES
Agriculture
Natural Resources Management

COMMUNICATION
Journalism
Radio & Television
Telecommunications

PUBLIC AFFAIRS
Emergency Management
Law Enforcement
Public Administration

COMPUTERS & INFORMATION SCIENCES

BUSINESS TYPES

(Select appropriate types(s) and enter in item 13 of this form)
AGRICULTURE
Crops
Forestry
Livestock
Services

MANUFACTURING (Continued) SERVICES (Continued)
Textile
Legal
Tobacco
Lodging Places
Transportation Equipment
Membership Organizations
Miscellaneous Repair
Motion Pictures
MINING
Personal
Coal
Recreation
Metal
Sanitary
Nonmetallic
Social
Petroleum & Gas
Telocommunications

COMMUNICATION
Cable
Radio & Televesion
Radiotelephone
Telegraph
CONSTRUCTION
Building
Other than building
Special Trade

PUBLIC ADMINISTRATION
Economic
Environmental & Housing
Finance
General Government
Human Resources
International
Justice

FINANCE
Banking
Credit Agencies
Stock Brokerage
INSURANCE
Agents & Brokers
Carriers

REAL ESTATE
Agents & Managers
Operators & Lessors

MANUFACTURING
Apparel & Fabrics
Chemicals
Electrical & Electronic Machinery/Equipment/Suppliers
Fabricated Metal
Food
Furniture & Fixtures
Industrial/Commercial/Computer Equipment
Leather
Lumber & Wood (composite)
Machinery
Measuring & Controlling Instruments
Paper
Petroleum
Primary Metals
Printing & Publishing
Rubber & Plastics
Stone Clay Glass & Concrete

Water

TRANSPORTATION
Air
Local
Motor Freight & Warehousing
Railroad
U.S. Postal Service

WHOLESALE TRADE
Durable
Nondurable

RETAIL TRADE
NONCLASSIFIABLE
Apparel
ESTABLISHMENTS (Specify)
Automotive Dealers & Gasoline
Stations
Building materials Hardware & Garden Supply
Eating & Drinking Places
Food
Furniture
General Merchandise
SERVICES
Automotive Repair
Business
Computer
Consulting
Educational
Electric
Engineering/Accounting/Research/Management
Gas
Health

(Please detach this portion before submitting this form)