Fema Form 119-25-1 - General Admissions Application - 2012
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1
2DEPARTMENT OF HOMELAND SECURITY
O.M.B. No. 1660-0100
See Reverse for
FEDERAL EMERGENCY MANAGEMENT AGENCY
Expires November 30, 2016
Privacy Act Statement
GENERAL ADMISSIONS APPLICATION
PERMANENT
SECTION I - GENERAL INFORMATION
1. U.S. Citizen
If No, City and Country of Birth:
YES
NO
RESIDENT
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
5. WORK PHONE NO. (
)
zip code)
6. HOME PHONE NO. (
)
7. FAX NO.
(
)
8. E-MAIL ADDRESS:
9a. ENTER COURSE CODE AND TITLE: (If you wish to apply for more than one course,
9b. COURSE LOCATION
9c. DATES REQUESTED (Please give three choices)
please attach a sheet of paper to this application)
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. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
14 a. JURISDICTION
14 b. ORGANIZATION
15. CURRENT STATUS
FOREIGN
SPECIAL DISTRICT/TOWNSHIP
PAID FULL TIME
1.
4.
7.
1.
STATEWIDE
ALL CAREER
1.
PAID PART TIME
2.
2.
5.
8.
DHS/FEMA
2.
ALL VOLUNTEER
COUNTY GOVERNMENT
FEDERAL/MILITARY (non-DHS)
VOLUNTEER
3.
CITY/TOWN/VILLAGE
3.
6.
9.
TRIBAL NATION
3.
COMBINATION
DISASTER RESERVIST
INDUSTRY/BUSINESS
4.
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.
17a. PRIMARY RESPONSIBILITY
17b. TYPE OF EXPERIENCE
17c. NUMBER OF YEARS OF EXPERIENCE
1.
1.
INCIDENT COMMAND
MANAGEMENT
ADMINISTRATION/STAFF SUPPORT
2.
2.
TRAINING/EDUCATION
17d. SIZE OF DEPARTMENT
SUPERVISION
3.
SCIENTIFIC/ENGINEERING
3.
BUDGET/PLANNING
17e. BUSINESS TYPE
4.
INVESTIGATION
4.
PROGRAM DEVELOPMENT/DELIVERY
1.
GOVERNMENT
FIRE PREVENTION
5.
5.
COORDINATION/LIAISON
FIRE SUPPRESSION
6.
6.
EDUCATION
2.
PROGRAM/ACTIVITY
PUBLIC EDUCATION
7.
7.
FIRE SERVICE
3.
HEALTH
CODE DEVELOPMENT
8.
8.
LAW ENFORCEMENT
4.
PUBLIC WORKS
CODE ENFORCEMENT/INSPECTION
9.
9.
VOLUNTEER AGENCY
5.
DISASTER RESPONSE/RECOVERY
SUPPORT SERVICES
10.
10.
EMERGENCY MANAGEMENT
6.
EMERGENCY MEDICAL SERVICE
RESEARCH AND DEVELOPMENT
11.
11.
HEALTH CARE
7.
HAZARD MITIGATION
ARSON
12.
12.
PUBLIC WORKS
EMERGENCY PREPAREDNESS
LAW ENFORCEMENT
8.
13.
13.
OTHER
DESIGN AND PLANNING
14.
14.
(Specify)
OTHER (Specify)
15.
19. GENDER
18. DATE OF BIRTH
Male
Female
20. RACE (Please check all that apply)
20a. Ethnicity
HISPANIC or
NOT HISPANIC
AMERICAN INDIAN or
BLACK or AFRICAN
NATIVE HAWAIIAN or
3.
1.
2.
ASIAN
4.
WHITE
5.
LATINO
or LATINO
ALASKAN NATIVE
AMERICAN
PACIFIC ISLANDER
FEMA Form 119-25-1, (2/12)
PREVIOUS EDITION FF75-5 OBSOLETE
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