Form FEMA Form 119-25-1 FEMA Form 119-25-1 General Adminissions Application

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

GENERAL ADMISSIONS APPLICATION
SECTION I - GENERAL INFORMATION

1. U.S. Citizen

YES

PERMANENT
RESIDENT

NO

O.M.B. No. 1660-0100
Expires August 31, 2013

See Reverse for
Privacy Act Statement
If No, City and Country of Birth:

2. NAME (Last, First, Middle Initial, Suffix)

3. STUDENT IDENTIFICATION (SID) NUMBER

4. HOME MAILING ADDRESS (Street, avenue, road no, P.O. box/city or town, state, and
zip code)

5. WORK PHONE NO. (

)

6. HOME PHONE NO. (

)

7. FAX NO.

)

(

8. E-MAIL ADDRESS:
9b. COURSE LOCATION

9a. ENTER COURSE CODE AND TITLE: (If you wish to apply for more than one course,
please attach a sheet of paper to this application)

9c. DATES REQUESTED (Please give three choices)

10. COMPLETE THE ITEMS BELOW REGARDING THE PREREQUISITES OF THE COURSE FOR WHICH YOU ARE APPLYING
INSTITUTION

DEGREE/CERTIFICATE

DATE EARNED

COURSE/FIELD OF STUDY

11. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL ASSISTANCE DURING YOUR ATTENDANCE IN TRAINING?
(If yes, describe & indicate any special assistance required on a separate sheet)
YES
NO
SECTION II - EMPLOYMENT INFORMATION AND AUTHORIZATION

12a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED

12b. NFIRS #
13. CURRENT POSITION AND NUMBER OF YEARS IN
(NFA STUDENTS ONLY) POSITION

14 a. JURISDICTION
1.
STATEWIDE

4.

14. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
14 b. ORGANIZATION
FOREIGN
SPECIAL DISTRICT/TOWNSHIP
1.
7.
ALL CAREER

2.

COUNTY GOVERNMENT

5.

FEDERAL/MILITARY (non-DHS)

8.

DHS/FEMA

2.

ALL VOLUNTEER

3.

CITY/TOWN/VILLAGE

6.

INDUSTRY/BUSINESS

9.

TRIBAL NATION

3.

COMBINATION

15. CURRENT STATUS
PAID FULL TIME
1.
PAID PART TIME
2.
VOLUNTEER
3.
4.

DISASTER RESERVIST

16. Briefly describe your activities/responsibilities as they relate to the course for which you are applying and identify how you will use the information obtained from the
course. Attach an organizational chart for the organization being represented and indicate your position. If you need more space, please attach a sheet to this application.

17. CHECK ONE BOX IN EACH COLUMN THAT BEST DESCRIBES YOUR PRESENT PRIMARY RESPONSIBILITY AND TYPE OF EXPERIENCE AS IT RELATES TO THE COURSE FOR
WHICH YOU ARE APPLYING. ALSO ENTER THE NUMBER OF YEARS OF EXPERIENCE.

17c. NUMBER OF YEARS OF EXPERIENCE

17a. PRIMARY RESPONSIBILITY
1.
MANAGEMENT

17b. TYPE OF EXPERIENCE
1.
INCIDENT COMMAND

2.

TRAINING/EDUCATION

2.

ADMINISTRATION/STAFF SUPPORT

3.

SCIENTIFIC/ENGINEERING

3.

SUPERVISION

4.

INVESTIGATION

4.

BUDGET/PLANNING

17e. BUSINESS TYPE

17d. SIZE OF DEPARTMENT

5.

FIRE PREVENTION

5.

PROGRAM DEVELOPMENT/DELIVERY

1.

GOVERNMENT

6.

FIRE SUPPRESSION

6.

COORDINATION/LIAISON

2.

PROGRAM/ACTIVITY

7.

PUBLIC EDUCATION

EDUCATION

7.

HEALTH

3.

8.

CODE DEVELOPMENT

FIRE SERVICE

8.
9.

PUBLIC WORKS

9.

CODE ENFORCEMENT/INSPECTION

4.

LAW ENFORCEMENT

10.

DISASTER RESPONSE/RECOVERY

10.

SUPPORT SERVICES

5.

VOLUNTEER AGENCY

11.

EMERGENCY MEDICAL SERVICE

11.

RESEARCH AND DEVELOPMENT

6.

EMERGENCY MANAGEMENT

12.

HAZARD MITIGATION

12.

ARSON

7.

HEALTH CARE

13.

EMERGENCY PREPAREDNESS

13.

LAW ENFORCEMENT

8.

PUBLIC WORKS

14.

OTHER (Specify)

14.

DESIGN AND PLANNING

15.

OTHER (Specify)
19. GENDER
Male

18. DATE OF BIRTH
20. RACE (Please check all that apply)
AMERICAN INDIAN or
ASIAN 3.
2.
ALASKA NATIVE

1.

FEMA Form 119-25-1, (2/12)

BLACK or AFRICAN
AMERICAN

4.

WHITE

5.

Female
NATIVE HAWAIIAN or
PACIFIC ISLANDER

PREVIOUS EDITION FF75-5 OBSOLETE

20a. Ethnicity
HISPANIC or
LATINO

NOT HISPANIC
or LATINO

SECTION III - ENDORSEMENT AND CERTIFICATION

21a. I certify that the information recorded on this application is correct. Falsification of information will result in denial of a course certificate and stipend (18 U.S.C. 1001).
21b. 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 or designee.
21c. 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.
21d. 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.
DATE

SIGNATURE OF APPLICANT
22. APPROVAL BY THE HEAD OF THE SPONSORING ORGANIZATION

"By signing this application, I certify that my organization does not discriminate on the basis of age, gender, race, color, religious belief, national origin, economic status, or
disability in providing educational opportunities for its employees."
22a. SIGNATURE

22b. PRINTED NAME AND TITLE
23. ADDITIONAL ENDORSEMENTS FOR APPLICATION TO THE EMERGENCY MANAGEMENT INSTITUTE:

23a. SIGNATURE AND DATE (State Office)

23b. SIGNATURE AND DATE (FEMA Regional Office)

24a. FOR NFA REGIONAL DELIVERY COURSES AND COURSES
DELIVERED AT EMMITSBURG, MD. SUBMIT APPLICATION TO:

24b. FOR EMI COURSES DELIVERED AT NETC, MWEOC, OR NTF
SUBMIT APPLICATION THROUGH THE APPROPRIATE STATE
EMERGENCY MANAGEMENT COORDINATOR OR FEMA REGIONAL
TRAINING MANAGER TO NETC.

NATIONAL EMERGENCY TRAINING CENTER
OFFICE OF ADMISSIONS, BLDG. I-216
16825 SOUTH SETON AVENUE
EMMITSBURG, MD. 21727
25. DISPOSITION
ACCEPTED

REJECTED

24c. FOR FIELD PROGRAM COURSES, SUBMIT APPLICATION TO
APPROPRIATE SPONSOR.

SIGNATURE OF REVIEWER

DATE

EQUAL OPPORTUNITY STATEMENT
NFA and EMI are Equal Opportunity institutions. They do not discriminate on the basis of age, gender, 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, gender, 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 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.

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 9 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 it displays a valid OMB control number. 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 (1660-0100). NOTE: Do not send your completed form to this address.