Fema Registration Form

U.S. Department of Homeland Security (DHS), Federal Emergency Management Agency (FEMA),

National Preparedness Directorate (NPD), National Integration Center (NIC), Training and

Exercise Integration Secretariat/Training Operations (TEI/TO)

REGISTRATION FORM

Fields displayed in bold* are required and must be completed. Please print characters in CAPITAL LETTERS only using BLACK ink.

Part 1: Course Information

Are you a federal employee

Yes

No

Training Provider Abbrev*

Are you a US citizen*

Yes

No

Course Name*

Start Date

Start Date

Course Catalog Number*

-

/

/

/

/

(First Choice)*

(Second Choice)*

(MM/DD/YYYY)

(MM/DD/YYYY)

Start Time*

.

Contact Hours

Convert start and end time

into military time.

City*

Training Method*

State*

ZIP Code

Resident

Mobile

Indirect

(For office use only)

Instructor Point of Contact

Last Name*

First Name*

Part 2: Student Information

Last Name*

First Name*

Middle Initial

Agency*

Job Title*

Email Address*

Work Address Information:

Work Address*

Work City*

Work State*

Work ZIP Code*

Work Phone Number*

-

-

Home Phone Number*

-

-

Level of Government*

Bubble in ONE item that best describes your level of government.

Local

State

Federal (DHS)

Federal (Non-DHS)

Not Applicable

Student Discipline*

Bubble in ONE item that best describes your discipline.

Agricultural Safety (Pre and Post Harvest) (AGS)

Governmental Administrative (GA)

Public Health (PH)

Animal Emergency Services (AES)

Hazardous Materials (HM)

Public Safety Communications (PSC)

Citizen/Community Volunteer (CV)

Healthcare (HC)

Public Works (PW)

Emergency Management (EM)

Information Technology (IT)

Search and Rescue (SR)

Emergency Medical Services (EMS)

Law Enforcement (LE)

Transportation Security (air, Water, Ground, Port) (TS)

Fire Service (FS)

Private Sector/Corporate Security and Safety Professionals (PSP)

Other (OTH)

Confidentiality of Information: Your responses and all personal information will remain confidential. Any reporting of data will be done anonymously in an aggregated fashion, without names or identifiers

Public Reporting Burden: Paperwork Reduction Act Notice. Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control

number. Forms are created and instructions provided so that they are accurate and can be easily understood while imposing the least possible burden on you to provide the requested information. The estimated

average time to complete and file this application is 15 minutes per form. If you have any comments regarding the accuracy of this estimate or suggestions for making this form simpler, please send to U.S.DHS / FEMA

Room 210b, North Tower, Tech World Bldg., 500 C Street, SW, Washington, D.C. 20472