Fema Registration Form (Page 2 of 2) in pdf

Fema Registration Form Page 2

Part 3: Required Signatures

Once both signatures in this block are signed, forward application to your state training point of contact for approval.

If you have any questions, please call the toll free registration line at 1-877-963-2867.

Applicant’s Name (Print) _____________________________________________________

Applicant’s Signature: _____________________________________________________ Date: ____/____/_______

Applicant's Supervisor Signature: _________________________________________________ Date: ____/____/_______

Privacy Act Statement

The information requested on this form is protected by the Privacy Act of 1974. The purpose for requesting this information is to enable proper processing of your

information for access to the U.S. Department of Energy, Nevada Operations training facilities. Failure to provide the requested information may preclude processing your

training request.

To be approved by State Administrative Agent (SAA) and/or State Training Coordinator (STC)

SAA/STC Signature: _____________________________________________________ Date: ____/____/_______

Please forward approved registration form to Counter Terrorism Operations Support by email: ctosreg@nv.doe.gov fax: 702-295-7815 or 702-537-2639