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

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
GENERAL ADMISSIONS APPLICATION

FOR AGENCY USE ONLY

O.M.B. Control No. 1660-0100
Expires 11/30/2016

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 9 minutes. 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, 500 C Street, SW,
Washington, DC 20472-3100, Paperwork Reduction Project (1660-0100) NOTE: Do not send your completed form to this address.
PRIVACY ACT STATEMENT
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 FEMA training. 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.; 6 U.S.C. Section 763a; Title 44 U.S.C., Section
3101; Executive Orders 12127 and 12148; Title VII of the Civil Rights Act of 1964; and Section 504 of the Rehabilitation Act of 1973; Section 1204 (c) of the
Implementing Recommendations of the 9/11 Commission Act of 2007. Public Law 110-53, 121 Stat. 266 (codified at 6 U.S.C. §1102). PURPOSE - To determine
eligibility for participation in FEMA training. Demographic data is used for statistical purposes only. USES - FEMA may release information to: FEMA training
agency staff and partners to analyze application and enrollment patterns; a physician providing medical assistance to students during training; Board of Visitors
members to evaluate programmatic statistics; State, local, tribal agencies to provide FEMA training statistics; Members of Congress; and FEMA training program
contractors. EFFECTS OF NONDISCLOSURE - Though voluntary, failure to provide personal information on this form may delay application processing and
course completion certification.

SECTION 1 - GENERAL INFORMATION
1. U.S. Citizen

YES

NO

PERMANENT RESIDENT

If No, City and Country of Birth:

2. NAME as shown on valid ID (Last, First, Middle Initial, Suffix)

3. FEMA STUDENT IDENTIFICATION (SID) NUMBER

4. HOME MAILING ADDRESS (street, avenue road #, P.O. box/city or town, state,
and zip code)

5. WORK PHONE #
6. HOME PHONE #
7. CELL PHONE #

8a. WORK E-MAIL:

8b. PERSONAL E-MAIL:
9b. TRAINING LOCATION (N/A for Distance Learning)

9a. COURSE CATALOG #, CODE, TITLE, OR PROGRAM:
9c. DATES REQUESTED (Please give 3 choices)
1

9d. TRAINING COMPONENT OR PROVIDER ID

2

9e. TRAINING DELIVERY TYPE:

3
Resident

Non-Resident

Indirect

Distance Learning

Conference/Symposium

9f. AIRPORT OF DEPARTURE OR POV (CDP USE ONLY)
10. ATTACH PREREQUISITE CERTIFICATES OR OFFICIAL TRANSCRIPT
11. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL ASSISTANCE
DURING YOUR ATTENDANCE IN TRAINING?
YES
NO
SECTION 2 - EMPLOYMENT INFORMATION AND AUTHORIZATION
12. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED

13a. CURRENT POSITION

14. CHECK THE BOX BELOW THAT BEST DESCRIBES YOUR ORGANIZATION
14a. JURISDICTION
7.
1.
STATEWIDE/TERRITORIAL 4.
SPECIAL DISTRICT
INTERNATIONAL
5.
8.
2.
LOCAL GOVERNMENT
MILITARY
FEMA
6.
9.
3.
FEDERAL (NON-DHS)
PRIVATE SECTOR
TRIBAL NATION

10.

15. CURRENT STATUS

3.

1.

PAID FULL TIME

2.

PAID PART TIME

DHS

13b. YEARS IN
POSITION

14b. ORGANIZATION
1.
ALL CAREER
2.
ALL VOLUNTEER
3.

COMBINATION

VOLUNTEER

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. NFA ONLY: 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.

FEMA FORM 119-25-0-1 (08/14)

Page 1 of 2

GENERAL ADMISSIONS APPLICATION
18. GENDER (Required for lodging)

17. DATE OF BIRTH

Male
19. RACE (Optional - Please check the one that best applies)
BLACK or AFRICAN
AMERICAN INDIAN or
3.
5.
1.
AMERICAN
ALASKAN NATIVE
2.

ASIAN

4.

Female
19a. ETHNICITY (Optional)

NATIVE HAWAIIAN or
PACIFIC ISLANDER

HISPANIC or LATINO
NOT HISPANIC or LATINO

WHITE

20. DISCIPLINE (Check the box that best applies to your organization).
1.
2.
3.
4.
5.
6.

AGRICULTURE
EDUCATION

7.
8.
9.

HEALTH CARE
INFORMATION TECHNOLOGY

10.
11.
12.

HAZARDOUS MATERIALS
CITIZEN/COMMUNITY VOLUNTEER

13.
14.
15.

EMERGENCY MANAGEMENT
FIRE SERVICE

16.
17.
18.

EMERGENCY MEDICAL SERVICES

LAW ENFORCEMENT
PUBLIC HEALTH
PUBLIC SAFETY COMMUNICATIONS
GOVERNMENTAL ADMINISTRATIVE
SECURITY AND SAFETY
PUBLIC WORKS
SEARCH AND RESCUE
TRANSPORTATION
OTHER (PLEASE SPECIFY)

SECTION 3 - 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,
stipend, or travel reimbursement, if applicable (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. Further, I understand that this information is
available to all FEMA training facilities and their training partners.
21c. Further, I understand that FEMA training agencies and their training partners 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 the FEMA training agencies and their training partners. Failure to do so will result
in denial of the student stipend (if applicable), expulsion from the course, and possible barring from future courses.
SIGNATURE OF APPLICANT

DATE

22. APPROVAL BY SUPERVISOR OR HEAD OF 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. I have reviewed this application and certify that 1)
the applicant meets all the prerequisites and qualifications to attend this course; 2) attendance will contribute to the professional development of
the participant in support of this agency's emergency response mission."
22a. SIGNATURE AND DATE

22b. PRINTED NAME AND TITLE

22c. EMAIL ADDRESS

22d. TELEPHONE NUMBER

23. STATE OR REGIONAL APPROVAL (If Required)
23a. SIGNATURE AND DATE

23b. PRINTED NAME AND TITLE

23c. EMAIL ADDRESS

23d. TELEPHONE NUMBER

24. TRAINING COMPONENT DISPOSITION
ACCEPTED

SIGNATURE OF REVIEWER

DATE

REJECTED

EQUAL OPPORTUNITY STATEMENT
FEMA and their training partners 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.

FEMA FORM 119-25-0-1 (08/14)

Page 2 of 2