Form FEMA Form 064-0-9 FEMA Form 064-0-9 EMI Independent Study Course Enrollment and Test Answer

Department of Homeland Security (DHS), Federal Emergency Management Agency (FEMA)
Emergency Management Institute (EMI) Independent Study Program Course Enrollment Application
REPORT INFORMATION

MARKING INSTRUCTIONS
• Complete ALL data fields on this form.
• Use a No. 2 pencil or a blue or black ink pen only.
• Do not use pens with ink that soaks through the paper.

• Clearly PRINT all letters and numbers that are required.
• Make solid marks that fill the response area completely.
• Make no stray marks on this form.

CORRECT:

O.M.B. No. 1660-0046
Expires 9/30/2013

INCORRECT:

Personal information will not be shared based on Privacy Act provisions. Please refer to
the Privacy Act Statement on the last page of this form. Reports are compiled from all
information on this form. It is essential that the data fields are complete so that course
completion information can be furnished to Local, State, Tribal and Federal levels.

CENTER PERF

IF YOU HAVE ANY QUESTIONS ABOUT THE CORRECT INFORMATION TO INCLUDE ON THIS FORM, PLEASE CALL OUR OFFICE AT (301) 447-1200.
1 STUDENT RECORD DATA Clearly print requested data as it should appear in your Independent Study Student Record. Proofread all items on your application before mailing.
Last Name
First Name
M.I. Suffix

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FEMA Form 064-0-9, OCT 10

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NOTE: If you are unsure
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zip4/welcome.jsp) or call
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DHHS

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Other

TYPE OF ORGANIZATION OR AFFILIATION If you
selected an organization or affiliation other than "Private
Citizen", you are required to select only one of the
following categories.
Emergency Management
Fire Service
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Private Voluntary
Public Works
Military
Emergency Medical

2 ORGANIZATION OR AFFILIATION
Select the category that best describes your organization or affiliation. If you are not applying under an
organization or affiliation, please mark "Private Citizen" and continue to section 3. If your selection was
"NOT" Private Citizen, please continue completing this section.
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CURRENT STATUS in the organization or affiliation.
Paid Full Time
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Other Federal (not DHS)

Volunteer Or Paid Per Call
Disaster Reservist

DHS EMPLOYEES ONLY Select the DHS organization that you are representing. Organization or Affiliation Address Line 1 (if applicable)
FEMA
NDMS
Transportation Security Administration
Customs and Border Protection
U.S. Secret Service
Immigration and Customs Enforcement
Preparedness

U.S. Coast Guard
Management
Policy
Science and Technology
Citizenship and Immigration Services
DHS Other

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PLEASE DO NOT WRITE IN THIS AREA

SERIAL

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Organization or Affiliation Address Line 2 (if applicable)

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U.S. GOVERNMENT PRINTING OFFICE:2008–346-523

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Zip Code + Four
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262290-4:654321

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NOTE: If you are unsure of the zip code
plus four, please use the link
(http://zip4.usps.com/zip4/welcome.jsp)
or call your local post office.

Organizational Local Jurisdiction (if applicable)
(Borough, Township, etc.)

Tribal Name (if applicable)

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This form cannot be duplicated.
PLEASE DO NOT WRITE IN THIS AREA

SERIAL

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3

FINAL EXAM
Name:

Month Day
Please Print Name Clearly

0
1

Email Address
You may also send your email address to [email protected]

FINAL EXAM ANSWERS
Carefully and completely color in the
oval that represents your answer.
Use "a" for TRUE and "b" for FALSE.

CORRECT:
INCORRECT:

T F

4

5

a
a
a
a
a
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1.
2.
3.
4.
5.

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T F
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If your course includes an alphabetical suffix to
the course number it must be completely filled in.
For example: IS 100.LE must appear as
IS 00100.LE

.

IS
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Social Security No. or
**Program Pre-Assigned Number

• Make solid marks that fill the response area completely.
• Make no stray marks on this form.

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COURSE CODE
Enter the numeric portion of the course code in a
five-digit format (enter one-digit course codes
as 00001 thru 00009 and enter two-digit
course codes as 00010 thru 00099) and darken
in the corresponding ovals.

Date of Birth

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** If you want a unique identifier (Program Pre-Assigned Number), you may contact the Independent
Study Office at [email protected]. This action will take between 6 to 8 weeks.

Work Phone Number
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Home Phone Number
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Mailing Instructions

Please allow 6 to 8 weeks for the processing of your documents.
Do not fold this document during use or for mailing except as already creased.
Mail this form in a 9½ X 12 inch envelope.
Affix proper postage.
Include a return address.

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6. Mail to:

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H
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K
L
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N
O
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T
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X
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This form cannot
be duplicated.

National Emergency Training Center
EMI Independent Study Program
16825 South Seton Avenue
Emmitsburg, MD 21727-8998

Privacy Act

1. GENERAL: This information is provided pursuant to Public Law 93-569 (Privacy Act of 1974), December 31, 1974, for individuals applying for admission to the EMI Independent Study
Program.
2. AUTHORITY: 5 USC 301; 15 USC 2205; 44 USC 3101; 50 USC App 2253 and 2281; and EO 12127, 12148 and 9397; Title VI of the Civil Rights Act of 1964; and Section 504 of the
Rehabilitation Act of 1973.
3. PURPOSE: 1) To determine eligibility for participation in EMI Independent Study and NFA Self-Study courses; 2) to enroll citizens who are unable to attend traditional classroom
courses; 3) to certify successful completion of courses; and 4) maintain accurate records on behalf of the student.
4. 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) Members of the Board
of Visitors for the specific purpose of evaluating programmatic statistics; 3) Sponsoring colleges to provide college credit for completed courses; 4) Sponsoring State and local officials
and agencies to update/evaluate statistics of EMI participants; 5) Members of Congress seeking first party information; 6) Agency training program contractors and computer centers
performing administrative functions; and 7) Military personnel or training offices to award military credit for completed courses.
5 EFFECTS OF NONDISCLOSURE: Personal information is provided on a voluntary 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-579, Sec 7b; EO 9397 authorizes the collection of the SSN. The SSN is necessary because of the
large number of individuals who have identical names and dates of birth and whose identity 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 it, another number will be submitted, which may delay
processing of your application and/or course certificate.

6

EQUAL OPPORTUNITY STATEMENT

The Emergency Management Institute (EMI) and the National Fire Academy (NFA) 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. In addition, employment related decisions based on sexual orientation are prohibited. Both
schools make every effort to ensure equitable representation of minorities and women in their student bodies. Qualified minorities and women are encouraged to apply for all courses.

7

PAPERWORK BURDEN DISCLOSURE NOTICE — FEMA Form 064-0-9

Public reporting burden for this data collection is estimated to average .75 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and submitting this form. You are not required to respond to this collection of information unless a valid OMB control
number is displayed on 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, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0046). NOTE: Do
not send your completed form to this address.