Fema Form 119-25-1 - General Admissions Application - 2010
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1
2DEPARTMENT OF HOMELAND SECURITY
O.M.B. No. 1660-0100
See Reverse for
FEDERAL EMERGENCY MANAGEMENT AGENCY
Expires August 31, 2013
Privacy Act Statement
GENERAL ADMISSIONS APPLICATION
SECTION I - GENERAL INFORMATION
1. U.S. Citizen
YES
NO
If No, City and Country of Birth:
3. SOCIAL SECURITY NUMBER
2. NAME (Last, First, Middle Initial, Suffix)
4. HOME ADDRESS (Street, avenue, road no./city or town, state, and zip code)
5. WORK PHONE NO. (
)
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)
MGT-330 Homeland Security Exercise and Evaluation (HSEEP)
DFW Airport, Texas
2/28-3/01/12
Program Indirect Delivery
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
FEMA ISP
IS-120A
11. DO YOU HAVE ANY DISABILITIES (Including special allergies or medical disabilities) WHICH WOULD REQUIRE SPECIAL ASSISTANCE DURING YOUR ATTENDANCE IN TRAINING?
NO
YES
(If yes, describe & indicate any special assistance required on a separate sheet)
SECTION II - EMPLOYMENT INFORMATION AND AUTHORIZATION
12b. NFIRS #
13. CURRENT POSITION AND NUMBER OF YEARS
12a. NAME AND COMPLETE ADDRESS OF ORGANIZATION BEING REPRESENTED
(NFA STUDENTS
IN POSITION
ONLY)
14. CHECK THE BOX(ES) BELOW THAT BEST DESCRIBE YOUR ORGANIZATION
14 a. JURISDICTION
15. CURRENT STATUS
14 b. ORGANIZATION
SPECIAL DISTRICT/TOWNSHIP
7.
FOREIGN
4.
1.
ALL CAREER
1.
STATEWIDE
PAID FULL TIME
1.
8.
FEDERAL/MILITARY (non-DHS)
DHS/FEMA
5.
2.
COUNTY GOVERNMENT
PAID PART TIME
2.
ALL VOLUNTEER
2.
9.
INDUSTRY/BUSINESS
TRIBAL NATION
CITY/TOWN/VILLAGE
6.
3.
VOLUNTEER
3.
COMBINATION
3.
DISASTER RESERVIST
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
2.
2.
ADMINISTRATION/STAFF SUPPORT
TRAINING/EDUCATION
17d. SIZE OF DEPARTMENT
3.
3.
SUPERVISION
SCIENTIFIC/ENGINEERING
4.
4.
BUDGET/PLANNING
17e. BUSINESS TYPE
INVESTIGATION
5.
5.
1.
PROGRAM DEVELOPMENT/DELIVERY
GOVERNMENT
FIRE PREVENTION
6.
6.
COORDINATION/LIAISON
FIRE SUPPRESSION
2.
EDUCATION
7.
7.
PUBLIC EDUCATION
PROGRAM/ACTIVITY
3.
FIRE SERVICE
8.
8.
CODE DEVELOPMENT
HEALTH
4.
LAW ENFORCEMENT
9.
9.
CODE ENFORCEMENT/INSPECTION
PUBLIC WORKS
5.
VOLUNTEER AGENCY
10.
10.
SUPPORT SERVICES
DISASTER RESPONSE/RECOVERY
6.
EMERGENCY MANAGEMENT
11.
11.
EMERGENCY MEDICAL SERVICE
RESEARCH AND DEVELOPMENT
7.
12.
12.
HEALTH CARE
HAZARD MITIGATION
ARSON
13.
13.
8.
EMERGENCY PREPAREDNESS
LAW ENFORCEMENT
PUBLIC WORKS
14.
OTHER (Specify)
14.
DESIGN AND PLANNING
15.
OTHER (Specify)
19. GENDER
20a. ETHNICITY
18. DATE OF BIRTH
Female
Male
HISPANIC or LATINO
NOT HISPANIC or LATINO
20b. RACE (Please check all that apply)
NATIVE HAWAIIAN or PACIFIC ISLANDER
BLACK or AFRICAN AMERICAN
4.
WHITE
5.
3.
AMERICAN INDIAN or ALASKA NATIVE
ASIAN
1.
2.
FEMA Form 119-25-1, AUG 2010
PREVIOUSLY FEMA Form 75-5
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