Form FEMA Form 119-17-1 FEMA Form 119-17-1 Request For Housing Accommodations

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. No. 1660-0029
Expires December 31, 2010

REQUEST FOR HOUSING ACCOMMODATIONS
PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection 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 this form. This collection of information is required
to obtain or retain benefits. You are not required to respond to this collection of information unless it displays a valid OMB control number. 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, and Paperwork Reduction Project (1660-0029). NOTE: Do not
send your completed survey to the above address.
PRIVACY ACT STATEMENT
GENERAL - This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals applying for housing at the National Emergency Training Center.
AUTHORITY - Public Law 93-498, 15 U.S.CA. 2206, 5 Up. So. CA. 301, 44 Up. So. CA. 3101, 50 Up. So. CA.Ape. 2253, E.O. 12127 and E.O. 12148.
PURPOSES: The principal purpose of the information requested on this form will be used to assign housing at the National Emergency Training Center. Information such as sex is necessary
because the accommodations are of the dormitory type and it is necessary to separate individuals by sex. Information will only be used or released as permitted by law.
EFFECTS OF NONDISCLOSURE - Personal information provided in this form is given on a volunteer basis as is assignment of housing. Failure to provide this information, however, may result in
the inability to assign housing.
Information Regarding Disclosure of Your Social Security Number (SSN) Under PL 93-579, Section 7(b) - Solicitation of the SSN is authorized under provisions of E.O. 9397, dated
November 22, 1943. The disclosure of the SSN is voluntary and is only for record keeping purposes. The SSN is used as an identifier to match the person requesting housing with the correct
master record in order to better assist in assigning housing to student and guest. The use of the SSN is necessary because of the large number of individuals who have identical names and whose
identities can only be distinguished by the SSN.
STATUS

FEMA Employee

Contract Instructor

Contractor

Other Specify

* Must present a copy of travel authorization or invitational travel, if applicable, at the time of registration.
DATE OF ARRIVAL

DATE OF DEPARTURE

NAME OF INDIVIDUAL REQUESTING HOUSING

PURPOSE OF VISIT

IT IS REQUESTED THAT THE FOLLOWING PEOPLE BE PROVIDED HOUSING AT NETC
PERSONAL
INDENTIFICATION
NUMBER

NAME OF INDIVIDUAL

PURCHASE
ORDER NUMBER
(If any)

GENDER
(M/F)

SPECIAL ACCOMMODATIONS NEEDED

I certify that the housing requested above is accordance with FEMA Instructions covering housing policy will
be paid with a NETC fee schedule at NETC.

SIGNATURE (Individual Requesting Housing)

APPROVED
YES

SIGNATURE (Director, NETC Management and Operations designee)

NO

SIGNATURE (NETC Program Office Head or Official Designee)

BILLING INFORMATION USE ONLY

FEMA Form 119-17-1, JAN 08

Exempt for payment

Must pay prevailing rate

Housing included in cost

Housing not included in cost

HANDICAPPED
(Y/N)