Form FEMA Form 119-17-2 FEMA Form 119-17-2 Request For Use of NETC Facilities

O.M.B. No. 1660-0029
Expires March 31, 2014

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

REQUEST FOR USE OF NETC FACILITIES

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, 1800 South Bell Street, Arlington, VA 20598-3005, Paperwork
Reduction Project (1660-0029). NOTE: Do not send your completed survey to the above address.
PRIVACY ACT STATEMENT
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.
Purpose: This information is being collected for the primary purpose of assigning housing and/or training space at the National Emergency Training Center.
Routine Uses: The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This
includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 011 Training and Exercise Programs System of
Records System of Records Notice (April 6, 2011, 76 FR 19107) and upon written request, by agreement, or as required by law.
Disclosure: The disclosure of information on this form is voluntary; however, failure to provide the information requested may result in the inability to assign/
obtain housing and/or training space. Information such as gender is necessary because the accommodations are of dormitory type and it is required to
separate individuals by gender. Information will only be released as permitted by law.
1. CONTACT PERSON

2. TELEPHONE NUMBER (Include area code)

3. ORGANIZATION

4. ADDRESS

5. NAME OF CONFERENCE/SEMINAR/MEETING

6. DATES
FROM

7. ACTUAL NUMBER OF ATTENDANTS
a.

Government employees

b.

Non-government
employees (Including guest
speaker)

c.

TOTAL

8. ACTUAL NUMBER REQUIRING
OVERNIGHT LODGING
a.

Male

b.

Female

TO

9. WILL MEALS BE REQUIRED

Yes

NOTE: Lodging checks will be made
NOTE:
payable to the National Emergency Training
Center

No

Food checks will be made payable to
the Food Service Contractor

10. ROOM SPACE REQUIRED
a. Meeting room

b. Breakout Rooms
(number in each room)

c. Auditorium

d. Social/Evening

11. EQUIPMENT NEEDED

12. OTHER REQUIREMENTS

13. SIGNATURE

DATE

Please return the completed form to:
Special Groups Coordinator
NATIONAL EMERGENCY TRAINING CENTER
16825 South Seton Avenue
Emmitsburg, MD. 21727

Phone:
Commercial:
FTS:

FEMA Form 119-17-2, (3/2011)

PREVIOUSLY FF75-11

(301) 447-1179
652-1179