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

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
OMB Control Number: 1660-0029
Expiration: 5/31/2017

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, 500 C Street
SW, Washington, DC 20472, 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.C §. 2206, 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 and upon written request, by agreement, or as required by law. The
Department's full list of system of records notices can be found on the Department's website at http://www.dhs.gov/system-records-noticessorns
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.
2. TELEPHONE NUMBER (Include area code)

1. CONTACT PERSON
3. ORGANIZATION
4. ADDRESS

DRAFT

6. DATES

5. NAME OF CONFERENCE/SEMINAR/MEETING

7. ACTUAL NUMBER OF ATTENDANTS
a.

8. ACTUAL NUMBER REQUIRING
OVERNIGHT LODGING

b.

Government employees
Non-Government employees
(including guest speaker)

a.

Male

c.

TOTAL

b.

Female

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

10. ROOM SPACE REQUIRED
a. Meeting Room
b. Breakout Rooms (number in each room)

FROM

TO

9. WILL MEALS BE REQUIRED

YES

NO

NOTE: Food checks will be made payable to
the Food Service Coordinator

c. Auditorium

d. Social/Evening

11. EQUIPMENT NEEDED

12. OTHER REQUIREMENTS

13. SIGNATURE

14. DATE

Please return the completed form to:
Special Groups Coordinator
NATIONAL EMERGENCY TRAINING CENTER
16825 South Seton Avenue
Emmitsburg, MD, 21727
FEMA FORM 000-0-0 (05/15)

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