Form 3-2193 Training Application

U.S. Fish and Wildlife Service

Training Application

OMB Control No 1018-0115
Expires: 12/31/2014
Mail, fax or email application to:
Learning Management System Administrator
USFWS/NCTC
698 Conservation Way Shepherdstown, WV 25443
Phone: 304/870-7101 Fax: 304/876-7202
Email: [email protected] Web: http://nctc.fws.gov

National Conservation
Training Center
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COURSE INFORMATION: PLEASE PRINT
Course
Code:

Course
Name:

Course
Course
Date:
Location:
APPLICANT INFORMATION: PLEASE PRINT
Agency Check One
FWS
BLM
Other Federal
Other DOI
NPS
OSM
USDA, Forest Svc
Tribal
Name (Last, First, MI)

If course is at NCTC, will you be:
Commuting
On-Site Accommodations
State/Local Agency
Public Municipality

Private Indiv/Business
University
Not for Profit
International
Federal Series/Grade:

Organization/Agency:

Job Title:

Section/Division

Organization Code (DOI Only)

Mailing Address:

FWS Region & Program:(FWS only)

City/State:

Zip Code:

E-mail Address:

Business Phone:

Have you ever been affiliated with a DOI Bureau in the past? Yes No
Supervisor Name:
Supervisor Email
Supervisor Signature:

Business Fax:

If so, which Bureau?

Supervisor Phone:

Special Needs Or Requirements?

BILLING/PAYMENT INFORMATION – MUST BE COMPLETE TO PROCESS YOUR APPLICATION
1. Billing Contact Name:
2. Billing Contact Phone & E-mail:
3. Billing Contact Organization:

4. ALC or Org T ax ID #:
5. DUNS #:
7. City/State Zip Code:

6. Mailing Address:

8. Credit Card Number, Funding Code or Voucher Number:
Payment Method:

Credit Card (1, 2, 3, 6, 7, 8 & 9)

Federal SF182 (IPAC)(1, 2, 3, 4, 5, & 8)

9. Expiration Date:
Interagency Agreement (1, 2, 3, 4 & 8)

Invoice(1, 2, 4, 5, 6, 7)
We do not invoice other gov't agencies

IF YOU NEED TO CANCEL YOUR REGISTRATION, please email or fax your cancellation request, including a reason for cancellation, to the appropriate Course
Coordinator or to the Course Registrar at [email protected]. Cancellation requests should be made more than 4 weeks prior to class start date to avoid
late cancellation penalty fees.

The Privacy Act of 1974; Statute Title 5, US Code, Chapter 41; Section 5, C.F.R., part 410; and 131 & 2 31 FW1 Training Management Policy and Responsibilities, authorizes the
collection of this information. This data will be used t o validate training records and meet statistical reporting requirements to Office of Personnel Management, Human Resources, and
Office of Management and Budget
FWS Form 3-2193
v 05/08

APPLICATION FOR FEDERAL NATIONAL CONSERVATION TRAINING CENTER
FISH AND WILDLIFE TRAINING
NOTE: THIS PAGE DOES NOT NEED TO ACCOMPANY THE APPLICATION WHEN SUBMITTED TO THE REGISTRAR
PAPERWORK REDUCTION ACT AND THE PRIVACY ACT NOTICES
IN ACCORDANCE WITH THE PAPERWORK REDUCTION ACT OF 1995 (44 U.S.C. 3501, ET SEQ.) AND THE PRIVACY
ACT OF 1974 (5 U.S.C. 552A), PLEASE BE ADVISED THAT:
1.

The gathering of information on personnel training activities is authorized by:
(a) The Privacy Act of 1974;
(b) Statute Title 5, US Code, Chapter 41;
(c) Section 5, C.F.R., part 410;
(d) and 231 FW1 Training Management Policy and Responsibilities, authorizes the collection of this information.

2.

Information requested in this form is purely voluntary, however, submission of requested information is required in order to process applications for
training courses authorized under the above acts. Failure to provide all requested information is sufficient cause for the U.S. Fish and Wildlife
Service, National Conservation Training Center to deny an applicant a place in a course. We may not collect or sponsor and you are not required
to respond to a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number.

3.

The National Conservation Training Center - Training Application training authorized under (a) The Privacy Act of 1974; (b) Statute Title 5, US
Code, Chapter 41; (c) Section 5, C.F.R., part 410; (d) and 231 FW1 Training Management Policy and Responsibilities, authorizes the collection of
this information and will be published in the Federal Register as required.

4.

Routine use disclosures are used solely as a statistical research or reporting and is transferred in a form that is not individually identifiable. Non
routine use disclosures will follow the requirement’s of “The Privacy Act of 1974 5 U.S.C. 522a (b) conditions of disclosure” such as under the
following conditions:
To officers and employees who have a need in performance of their duties;
To representatives for civil or criminal law relating to enforcement activity or pursuant to the order of a court;
To the House of Congress or committee or joint committee of Congress;
To the Comptroller General or any of her authorized representatives;

5.

For individuals, personal information such as home address and telephone number, financial data, and personal identifiers will be removed
prior to any release of the information.

6.

The public reporting burden for this information collection varies with the convenient availability of the requested information. The relevant burden
for the Training application averages 10 minutes. This burden estimate includes time for reviewing instructions, gathering and maintaining data and
completing and reviewing form. Direct comments regarding the burden estimate or any other aspect of the form to the Service Information
Clearance Officer, Fish and Wildlife Service, Mail Stop 2042-PDM, U.S. Department of the Interior, 1849 C Street, NW, Washington,
D.C. 20240.
Freedom of Information Act - Notice

For organization, businesses, or individuals operating as a business, we request that you identify any information that should be considered privileged
and confidential business information to allow the Service to meet its responsibilities under FOIA. Confidential business information must be clearly
marked “Business Confidential” at the top of the letter or page and each succeeding page, and must be accompanied by a non-confidential summary of
the confidential information. The non-confidential summary and remaining documents may be made available to the public under FOIA [43 CFR
2.13(c)(4), 43 CFR 2.15(d)(1)(i)].
Application Processing Fee
The US Fish and Wildlife Service, National Conservation Training Center does not collect an application-processing fee.